willwill!)munlTumultmull __ Q, 01570 312 l LlenAnir Michigan State University This is to certify that the dissertation entitled The Trimodal: A Training Model for Marriage and Family Therapy presented by < Janice Ruth Beuschel has been accepted towards fulfillment of the requirements for Ph.D. degmin Family and Child Ecology MS U it an Affirmative Action/Equal Opportunity Institution 0-12771 j . 3. A. ~ bet—“Jan“, PLACE ll fifiUflfiBDXto remove thb chockom from your record. TO AVOID INES .7“ r - . or; - or. data duo. DATE'DUE ‘“ DATE DUE DATE DUE HR 1 2 3995 1 MSU Is An Affirmative WM Opportunity Instituion W THE TRIHODAL: A TRAINING MODEL FOR.HARRIAGB AND PAMIL! THREAD! 31' Janice Ruth Beuechel A DISSBRIAIION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OP PHILOSOPH! Department of Family and Child Ecology 1997 ABSTRACT THE TRIMODAL: A TRAINING MODEL FOR MARRIAGE AND FAMILY THERAPY BY Janice Ruth Beuschel The replicability of the Trimodal Coding System was investigated as a training tool for marriage and family therapy interns in university training programs. A total of twenty marriage and family therapy interns participated in a five hour training workshop and completed a twenty-four item assessment instrument. Their performance on the assessment instrument was used to calculate the participants’ agreement with each other and and a group of experts in identifying productive and nonproductive dyadic interaction using the Trimodal Coding System. Twenty-four research questions and six hypotheses were investigated using a correlation coefficient and Cohen's kappa to correct for chance. The replicability of the Trimodal Coding System was largely supported. Three distinctions were evaluated on the assessment instrument. Good replicability was found in the productive/nonproductive distinction. Excellent replicability was found in the three productive modality distinction. Poor replicability was found in the nonproductive modality distinction. The results of this research support the usefulness of the Trimodal Coding System as a training tool for Marriage and Family Therapist interns. Copyright by Janice Ruth Beuschel 1997 To Wayne "What you can do or dream you can, begin it." GOETHE iv IR MORANDUH With the death of Dr. Albert DeVoogd in November, 1995, the Association for Marriage and Family Therapy suffered a great loss. Through decades of work as a therapist, Al created and expanded the Trimodal Metamodel. He wanted to share his knowledge with others. It was increasingly difficult for him to convey the ever growing expanse of his knowledge. ‘Yet, he continued.to teach, mentor and support all those who shared his interest in the Trimodal Metamodel. This researcher's project documented the Trimodal Metamodel, assessed its replicability, and provided a basis for further research. Further development of the Trimodal Metamodel will be dependent upon the proteges of Dr. Albert DeVoogd. Continued refinement and expanded applications of Trimodal will reflect their individual interests and abilities. The researcher is forever grateful to Dr. Albert DeVoogd whose life work, the Trimodal Metamodel, provided her with an organizational structure for doing marital and family therapy and this research project. For six years, he gave time, energy and support to her study of his model, always dealing with.my struggle to grasp what he considered the obvious. Re is missed. ACHOWLBDGERTS Although a dissertation appears credited to a single researcher, between every line is a support network of behind- the-scenes people. .As I read.my own words on these pages, the faces, words and love of my "network" remind me of the importance of process not just product. FAMILY My parents, Edward and Lorraine Gatz, knew before I did that being a teacher was my destiny. Their love and support gave me a solid foundation. Their value for education led me to love being a student also; however, this lasted much longer than any of us would have guessed! Thank you for all the sacrifices you made. Thank you to my younger brother, George, who bore the burden of having an older sister who loved being a student. Although we walked the same paths, our experiences were different as we have found out as adults. I'm thankful that our differentness has brought us closer. My nuclear family has been a great source of strength and encouragement. My husband, Wayne, has supported my Ph.D. aspirations since I first verbalized them as an undergrad at N.I.U. His unconditional love, humor and sacrifices have helped me stay the course. My children, William and Jensine vi have cheerfully and lovingly said, "GO FOR IT" in so many ways. And when all else failed, they reminded me I was their role model - that one always worked! FRIENDS A cluster of wonder friends have helped me maintain the balance between the isolation of research and the real world. Thank you for your humor, compassion and goodwill; Tim and Neesa Raha and Pam and Martyn Hempston. Thank you Rita Jay Galwich for your continuing friendship and sisterhood since our days at N.I.U. You all have a very special place in my heart. DOCTORAL COMMITTEE Thank you to my committee who each played a special part in my growth as a grad student at Michigan State University (M.S.U.): Dr. Dennis Keefe, my first advisor, whose mentorship during an independent study guided me through new thoughts and challenged me to become a more critical thinker. Dr. Richard Johnson, whose cheerful smile, humor and practicality showed me a different side of professorship. Dr. Robert Boger, a creative researcher and program developer who encouraged me to explore the opportunity of participating in the new Marriage and Family Therapy Program at MQS;U. Dr. Donald Melcer, who provided a calm oasis in the middle of grad student chaos and.mentored the therapeutic stance. Thank you all for demonstrating professionalism, providing encouragement and preserving the long journey of my dissertation. vii OTHER REY SUPPORTERS When I was accepted as a marriage and family therapy intern at the Marriage and Family Center, I had no idea what a wonderful training opportunity I was about to experience. The willingness of the staff to provide guidance, support and encouragement to a struggling Trimodal novice was what kept me going. Thank you Bob Huizenga for your supervision during my fledgling steps as a therapist in the Muskegon office. A. special thanks to Barbara Beerthuis for the many hours of supervision that guided me down the path of differentiation, stress reduction and the nuances of Trimodal. Your cheerful voice, or Aaron's, always let me know I could ask for help. Thank you Dr. Andrew Atwood, for eulogizing the life of Albert DeVoogd in a.way that helped us all to see the wonderful gift we were given, "Room for Living." Your summarization of Trimodal helped me understand the interlacing of Al's values in his work. Thank you to my colleagues at Child and Family Services of Western Michigan in Grand Haven, especially Thea Gerrish, Sandra Klein Horsman, Gail Harrison, Jan Gleason, and Diane Davis, who consoled me when the going got tough and celebrated with me as each step fell into place. A special thanks to Diane, my typist extraordinaire, whose "no problem" attitude kept things running smoothly through a maze of drafts, edits and final copies. This was a learning experience for both of viii us. A final thank you to Marcy Rosen who supported my research in both thought and action. Thank you to Dr. Dolores Harland-Hunt, Michigan State University and Dr. William Abler, University of Illinois at Springfield for the support they gave this research project. Without their hands-on efforts to bring news of this training opportunity to Marriage and Family Therapy interns, the difficult job of achieving an adequate sample would have been that much more difficult. My gratitude also to all the interns who participated in this research project. As most grad students' resources are stretched to the max, I greatly appreciate the time you gave me. ix TABLE OF CONTENTS LIST OF TABLES. OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO ........ Xiv LIST OF FIGURES..........OOO......OOOOOOO......OOOOOOOOO xv CHAPTER I: INTRODUCTION. ..................... ........... 1 Scope of Problem..................... ..... ............ 1 Statement of Problem.................................. 3 Significance and Generalizability..................... 3 CHAPTER II: REVIEW OF LITERATURE........................ 5 Foundation Movements of Marriage and Family Therapy... 6 Professions That Focus on Family Relations............ 10 History of Conceptual Models.............. ..... ....... 14 Systems Theory......... ..... ............... ..... ... 14 General Systems Theory.. ....................... .... 16 Family Systems Theory............................. 19 Major Schools of Marital and Family Therapy Theory. 24 Psychoanalytic Family Therapy and Theory......... 26 Bowenian Family Therapy and Theory............... 27 Contextual-Relational Family Therapy and Theory.. 28 Experiential Family Therapy and Theory........... 29 Communicational-Interactional Family Therapy andTheorYeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee 30 Structural Family Therapy Theory................. 32 Strategic-Systems Therapy and Theory.. ......... .. 34 X Behavioral and Problem Solving Therapies and Theory................................... 36 Coding Family Behavior.................................. 38 Establishing Criteria for Coding Interactional Data... 42 Marital Dyad Interactional Coding System.............. 44 Needs in Marriage and Family Therapy Assessment....... 48 Trimodal: A Meta-Model for Productive Dyadic InteractionOOOOOO0.0.00.0...0.00.00.00.00. 49 Basic Assumptions of the Trimodal..................... 53 Tenets of Trimodal.................................... 54 Trimodal Modalities................................... 55 Productive Interaction................................ 59 Nonproductive Interaction............................. 60 Trimodal Coding System................................ 62 Conclusion.......... ........ ..................... 63 CHAPTER III: METHODOLOGY................................ 64 Hypotheses............................................ 64 Population and Sample................................. 65 Procedures............................................ 67 Data Collection and Procedures........................ 69 Instrumentation....................................... 70 Data Analysis......................................... 76 Limitations and Assumptions........................... 77 Limitations....................................... 77 Assumptions....................................... 78 CHAPTER IV: RESULTS..................................... 79 Socioeconomic Data.................................... 79 FindingSOOOO0.0.......OOOOOOOOOOOOOOOOOO0.00.00.00.00. 80 xi Interaction Modality Coding...................... 80 Productive and Nonproductive Coding.............. 84 Nonproductive Modality Coding.................... 87 CHAPTER V: DISCUSSION.................................. 91 The Field of Marriage and Family Therapy............ 91 The Value of This Study............................. 92 Limitations........................................... 93 Weakneses in Sample Procurement..................... 93 Workshop and Materials Modifications................ 94 Evaluation of Assessment Instrument................. 95 finances of Data........................................100 Training vs. Instrument Design.....................1OO Subjects' Performance as Related to Amount of Clinical Hours........................101 Strength Of DataO O O O O O O O O ........... O ......... O O O O O 101 Strengths Of TrimOdal O O O O O O O O O O O O O O O O O O O OOOOOOOOOOO O O O O 102 Response of Workshop Participants..................102 Trimodal: A Pragmatic Approach to Marriage and Family Therapy...............................103 Training Model Viability...........................105 CHAPTER VI: SUMMARY AND IMPLICATIONS.. ..... ............106 Implications for Further Research..................110 Provisions for Further Research....................111 APPENDICES A. Introductory Letter to Perspective Participants workahOPSI&IIOOOOOOOOOOOOOOOOOOOO112 B. Participant Response and Confirmation Cards Workshops I & II....................113 xii F. LIST OF Introductory Letter to Perspective Participants workshop IIIOOOOOOOOOOOOOOOOOOOOOOOO114 Participant Response and Confirmation Cards workahop IIIOOOOOOOOOOOOOOOOOOOOOOOO115 Reminder Letter - Workshop III.................116 University of Illinois, Springfield Department Newsletter - Workshop IV............117 University of Illinois, Springfield Department Bulletins - Workshop IV.............119 Reminder Letter - Workshop IV..................120 Training Materials - Workshop I - IV...........121 Assessment Instrument - Workshop I.............138 Assessment Instrument - Workshops II - IV......143 Response Form - Workshops I - IV...............148 REFERENCESOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO152 xiii 9. 10. LIST OF TABLES Euclidean Co-efficient Intercorrelation Between Subjects and Between Subjects and Experts Not Corrected for Chance Regarding Interaction. Modality Coding’ by Individual Subjects.............................................82 Euclidean Co-efficient Intercorrelation.Between Subjects and Between Subjects and Experts Corrected for Chance Regarding Interaction. Modality Coding' by Individual Subjects.............................................83 Euclidean Co-efficient Intercorrelation Between Subjects and Between Subjects and Experts Not Corrected for Chance Regarding Productive and Nonproductive Coding by Individual Subjects..................................85 Euclidean Co-efficient Intercorrelation Between Subjects and Between Subjects and Experts Corrected for Chance Regarding Productive and Nonproductive Coding by Individual Subjects..................................86 Euclidean Co-efficient Intercorrelation Between Subjects and Between Subjects and Experts Not Corrected for Chance Regarding Nonproductive Modality Coding by Individual Subjects..............................................88 Euclidean Co-efficient Intercorrelation Between Subjects and Between Subjects and Experts Corrected for Chance Regarding Nonproductive Modality Coding by Individual Subjects..............................................89 Pooled Agreements of Subjects with Experts Using Cohen's Kappa.to Correct for Chance.............90 Frequency of Incorrect Answers by Question Part I Productive Modality Distinction. . . . . . . . . . . . . . . . 96 Frequency of Incorrect Answers by Question Part IIa.Productive and.Nonproductive Distinction.....98 Frequency of Incorrect Answers by Question Part IIb Nonproductive Use of Modality Distinction...100 xiv 3. 4. 5. 6. LIST OF FIGURES Kaslow's Model of Nine Theoretical Perspectives and Their Perspective Of TimeOOOOOOOOOOOOOOOOOOOOOOOOOOzs Kaslow's Model of Nine Theoretical Perspective and Their Theoretical Focal Points.....................25 The Trimodal Modalities. .......... . ....... ..........56 Skills Of TrimOdal OOOOO OOOOOOOOOOOOOOOOOOOOOOOOOOOOO57 Relational Position of Dyad in Each Modality........58 Identification of Statement Modality Part I of Instrument..............................72 Identification of Statement Modality Part II Of Instmenteeeoeeeeeeeeeeeeeeeeeeaeoeeee74 CHAPTER I: INTRODUCTION Scope of the Problem "The field of family therapy is a rapidly growing one by any standard used to assess such activity" (Gurman, 1981, p. 772). A wide variety of assessment tools, interventions, theoretical models are available to clinicians in this field. The variety can overwhelm therapists as they weave their way through therapy sessions wondering if they know where they're going therapeutically with their clients, much less where they've been. In order to cut through the deluge of information supplied by the rapid growth of this field over the past fifty years, clinicians are in need of a meta-model on which to organize the wealth of information offered by their profession and to assist them in their therapeutic treatment of families. The Trimodal Meta-Model offers therapists a clear and succinct model for assessment, intervention, goal setting and evaluation. In addition, this meta-model offers clinicians the opportunity to integrate and organize the information and theoretical models offered in the field of marriage and family therapy. Not only is it difficult to integrate the many theoretical l 2 models in marriage and family therapy in order to shape and direct their therapy, there is lack of conceptual models for training and evaluation of clinical interns, since supervisors must move from theoretical model to theoretical model to evaluate the knowledge and clinical skills of an intern. WAll of the considerations involved in designing studies on the outcomes of marriage and family therapy and reviews of the evidence of treatment effectiveness in this field will be of minimal value if our gradually accumulating knowledge and increasing methodological sophistication do not translate into direct implications for the training of future marital-family therapists. Moreover, research efforts need to be directed specifically to the process and outcomes of family therapy training methods" (Gurman, 1981, p. 772). The assessment of the process of interactions within the marital dyad can be made with currently available assessment tools, but they are both time and cost intensive. Moreover, currently it is not possible to structure interventions and assess change using the same assessment tool. Therefore, the profession of marriage and family therapy needs to have a tool that can be used throughout the therapy process for consistency in treatment from assessment through evaluation. Through the vision and effort of Dr. Albert DeVoogd, the Trimodal evolved, drawing on the many theoretical models available to clinicians, specifically' psychoanalytic, transactional, structured, object relations and behavioral. 3 The use of the term "meta" implies the models ability to integrate or draw from other models of therapy and represent a full range of interaction from individuals to families. The major contribution of this model is its ability to identify where the client is "available" to the therapist, as can be demonstrated through the use of the coding system based on this meta-model. Empirical research in marriage and family therapy is dependent upon methods that allow interactions to be coded. The delineation of the process of dyadic interaction through coding would allow empirical research to be done, not only on the husband-wife process, but also on the process of parent- child, sibling-sibling and therapist-client interaction. "Research efforts need to be directed specifically to the process and outcomes of family therapy" (Gurman, 1981, p. 772). Statement of the Problem This study sought to investigate the replicability of the Trimodal Coding System on dialogue segments taken from marital therapy sessions by trained subjects. Significance and Generalizability The main objective of this work was to evaluate a coding 4 system that can provide a time and cost effective training tool for marriage and family therapy interns and clinicians. This research was unique in that it provided the groundwork for specialized clinical training in the use of Trimodal. Since this model was process oriented, the gap between assessment and outcome in the field of marital and family therapy can be addressed. The use of the Trimodal Coding System can be generalized to other dyadic interaction systems, such as parent-child, child-child, adult-adult, teacher-student, therapist-client, or supervisor-clinician. In addition to the coding of specific types of dyadic interaction, coding can be generalized to target groups such as co-dependents, chemically dependents, neurotics and psychotics to identify their unique patterns of interaction. This research resulted in the development of instructional materials, an assessment instrument and assessment of the replicability of this coding system by marriage and family therapy interns. CHAPTER II: REVIEW OP LITERATURE History of Marriage and Family Therapy The development of the profession of Marriage and Family Therapy to address the problems of families is a unique feature of our culture in the 20th century. It grew in response to societal events that disrupted the structure and status of the family unit. In the twenty years following WWI, a period of social instability was paralleled by a loosening of family ties, an upswing in divorce and juvenile delinquency. Families experienced severe stress. From Prohibition to Social Security, from the Community Mental Health Movement to Women's Rights Movement attempts have been made to rectify these social ills (Broderick, 1981). The outbreak of WWII furthered the period of social upheaval and family disorganization. Four largely independent movements formed the basis for the development of Marriage and Family Therapy: the social work movement (1877) , the social psychiatry movement (1910), the sexology movement (1900's) and the family life education movement (1883) (Gurman & Kniskern, p. 5-6). Foundation Movements of Marriage and Family Therapy The social work movement, with its New York beginnings in 1877, was a response to the needs of the poor. Assistance given to the poor to meet their needs became known as "welfare". By 1908, social worker Mary Richmod was writing family oriented case records and in 1928, wrote "Concern of the Community with Marriage", stressing the importance of relationships when helping families. However, by 1930, the impact of psychiatry on social work led to a stronger focus on the individual and the American Orthopsychiatric Association was founded as a joint venture between the fields of social work and psychiatry. Although the initial interest of the social work field in the family waned at this time, it contributed, none-the-less, to the historical development among mental health professionals who focused on relationships in families. The social psychiatry movement was an outgrowth of Freud's psychoanalysis, whose central concept was instinctual libidinal drive as the force behind human behavior. Alfred Adler and Carl Jung were two of his students who felt Freud underestimated the impact of social elements on human behavior. In 1910, Alfred Adler was the first to openly challenge Freud's central concept. Adler felt that the diving force in life was the deeply internalized sense of inferiority 7 coming from. the smallness and helplessness of infancy. Therefore, he felt people are motivated by a compulsion to achieve feelings of adequacy and power. This could be achieved two ways: by fleeing into illness and dominating or manipulating through weakness (later called meta- complementarity by Watzlawick, Beavin and Jackson (1967), or by engaging those around us in an open power struggle. Carl Jung further expanded Adler's power struggle concept by looking at the impact of the affective state of the parents on the child and stating that "the more sensitive and moldable the child, the deeper the impression" (Gurman, 1987, p. 8). Both Adler and Jung developed concepts that viewed individual pathology as a product of family conflict. Two other well known analysts emerged from the social psychiatry movement. Eric Fromm, who emphasized the interaction between man and his society and Harry Stack Sullivan, who was the most interpersonally oriented analyst, were two of the most influential analysts. Fromm's emphasis on the interaction between man and his society echoed Jung's insights into social customs and viewed the development of individuality as a social process rather than as a fixed and biologically given nature. This View of the development of individuality foreshadowed the work of Bowen and others who focused on the importance of differentiation from.the family. Sullivan emphasized how the child's concept of self is shaped by how others respond to the various behaviors of that child. 8 This process is known as "reflective appraisals". In addition, two other aspects of Sullivan's work laid foundations for the family theorists to followu First, he was among the first to assert and demonstrate that schizophrenia could be treated by psychotherapy and second, he was foremost a clinician rather than a theorist, refusing to be impressed with any theory which could not be demonstrated in practice. By mid-century, when the family therapy pioneers were beginning to experiment, the American analysts had well established an orientation toward social emphasis in psychiatry. The sexology movement was led by Havelock Ellis of Great Britain and.Magnus Heirschfeld of Germany at the beginning of the 20th century. Both were physicians and neither were associated with psychiatry or social work. Ellis, having been raised in the Victorian era, vowed to do everything in his power to prevent others from experiencing the ignorance and discomfort he had as a young man. Listening with acceptance and support of his clients and recommending reading (usually his own writings) to them were hallmarks of his therapeutic style. He wrote the first major work on homosexuality. Heirschfeld founded the Institute of Sexual Science in Berlin in 1918 and in 1930 culminated his career with the five volume work entitled §ex_Egugatign. Ellis and Heirschfeld founded the World League for Sexual Reform, holding five international meetings in Berlin between 1921 and 1932. Hitler destroyed 9 Herschfeld's center in Berlin and converted his Marriage Consultation Consultation Bureau into public centers known as "Health and Racial Hygiene Bureaus". In the United States, human sexuality had become a legitimate arena for scientific research and sixteen studies of human sexuality were published by 1940. The works of Ellis, Heirschfeld and early American researchers formed a pool of scientific knowledge about human sexual behavior for later professionals, including marriage and family therapists, to draw upon. The family life education movement had its beginnings in the mother's groups of 1883 and the evolution of the American Home Economics Association founded in 1908. The Association created high school and college courses targeted at improving American homemaking. In the 1920's and 1930's, both Paul Popenoe and Ernest Groves played fundamental roles in the development of parenthood preparation courses at their respective institutions, Boston University and Vassar College. The home economists and sociologists teaching these courses were called upon by their students to do pre-marital and marital counseling, although usually they had no preparation to do so. In 1938, the National Council of Family Relations was founded for professionals involved in educating, studying and/or counseling families. The NCFR sponsored the publi- cation.of a professional journal, Mar;iage_gnd_£amily_niying. The founders of the family life education.movement were among the pioneers of the marriage counseling movement in America. 10 Professions That Focus On Family Relations These four foundation movements led to the present cluster of cross-borrowing, over-lapping professions which deal with relationships among family members: Marriage Counseling, Sex Therapy, Marital Therapy, and Family Therapy. The development of Marriage Counseling as a profession had its beginnings in the late 1920's to early 1930's, both in Germany and the United States. Early professionals in this field were doctors, lawyers, educators and social workers. By 1942, the American Association of Marriage Counselors was formed with the purpose of "establishing and maintaining professional standards in marriage counseling. " (Gurman & Kniskern, 1981, p. 13) By 1948, the American Association of Marriage Counselors and the National Council on Family Relations proposed a set of standards for post-graduate professional marriage counselors, and doctoral programs with a major in marriage counseling. By 1962, a code of ethics was established and the profession came of age in 1963 with the passage of a licensing law for marriage and family counselors in Califorina. The American Association of Marriage Counselors underwent several name changes, reflecting the shifting focus to inclusion of families and commitment to indepth therapeutic treatment and arrived at its current designation, The American Association for Marriage and Family ll Therapy. The American Association for Marriage and Family Therapy (AAMFT) is the professional organization representing 20,000 marriage and family therapists around the world. Since 1942, the AAMFT has been involved with the mental health needs and changing patterns of couples and families. The Association leads ‘the *way ‘to .increasing"understanding, research. and education in the field of marriage and family therapy, and to ensuring the public needs are met by trained practitioners. The AAMFT believes that therapists with specific education and training in marriage and family therapy provide the most effective mental health care to individuals, couples and families. "The AAMFT"s purposes are to promote the common interests of marriage and family therapists; to represent the discipline to the public and governmental bodies; to establish and maintain professional standard in marriage and family therapy education, training and practice; to facilitate research; to cooperate with related organizations; and to serve as a networking and information resource for persons interested in family' systems and. services." (AAMFT .Annual Convention Registration Form, 1992). The history of sex therapy began with a therapeutic tradition.which treats sexual disorders as practical problems that ought to yield to specific remedies. In America, sexual counseling followed the patterns set in Europe and most 12 practitioners came to the field from the social hygiene movement or from medicine. A gynecologist, Robert L. Dickinson, contributed greatly to the field of sex therapy with the 1933 publication of W, a large compilation of sex histories. In addition, he was a founding member of the American Association of Marriage Counselors. Alfred Kinsey also added immeasurably to the knowledge base of sex therapists by working with a research team that compiled thousands of comprehensive lifetime sex histories of both men and women. The publication of these findings raised the level of consciousness of Americans concerning their own sexual biases and behaviors. Masters and Johnson's publication, 3W, made a key contribution to the field of sex therapy by sharing their discovery of a stage organization of the human sexual response cycle. It was their second book, WW (1970), that set forth the clinical application of the human sexual response and revolutionized the field. They had determined that they would treat all sexual dysfunction as a problem of the pair rather than the individual and, as therapists, they would operate as a male- female team in all cases. Although the youngest of the professions, sex therapy has equally influenced the development of Marriage and Family Therapy. (Gurman 8. Kniskern, p. 28). The profession of Marital Therapy had its underpinnings in psychoanalysis and Freud's predominant concern with the 13 internal dynamics of human psyche. Psychoanalysts did not involve family members in therapy in order to avoid complications of multiple transference and counter- transference. However, by the early 1930's, papers were being written that addressed the psychoanalysis of married couples and "family diagnosis" (Gurman 8. Kniskern, p. 17). In 1959, Don Jackson coined the term "conjoint therapy” to describe a therapist meeting with a husband and wife together (Gurman 8. Kniskern, p. 17) . More articles on marital therapy were seen in psychiatric texts and journals. In the 1960's, a new journal, W, was devoted exclusively to Marriage and Family Therapy issues. By the 1960's and 1970's, the marital therapy movement became absorbed into the more broadly based family therapy movement. The Family Therapy profession gained prominence in the social upheaval and family disorganization following WWII. The decade of 1952-1961 is deemed the founding decade of this profession as pioneers of this movement made major steps towards establishing conjoint family therapy as an approach to treatment. The family was viewed as a resource and support system and used creatively as a force to bring about positive and lasting change in both the individual and family unit. "The pioneer theoreticians and therapists stimulated a true paradigmatic shift in the manner in which human problems were seen, reorienting their thinking regarding the nature of and the ways of modifying relationships and pathology" (Kaslow, 14 1987, p. 837). This shift lead to the development of new concepts. This shift lead to the development of new concepts to enhance and/or replace traditional thinking regarding etiology, symptom formation, diagnosis, and treatment of human problems. Various schools of thought have branched out from the family therapy tree since the mid 1950's. These will be discussed later in this chapter. History of Conceptual Models The foundation or meta-theory of marriage and family theory is systems theory. This section will present the history and basic concepts of systems theory, general systems theory, and family systems theory. W Systems theory originated in mathematics and later became closely linked with computer science. Systems theory was based on the concept of the interaction of the parts of an identifiable entity as defined by Allport, a system is a "complex of elements in mutual interaction" (Buckley, 1986, p. 344) . Systems theory denotes two types of systems, open and closed. A closed system is one that “admits no matter from outside itself and is therefore subject to entropy according to the second law of thermodynamics" (Buckley, 1968, p. 345) . 15 An open system is one in.which there is "interaction with the environment" (Laszlo, 1972, p. 61). There are four criteria of an open system: 1. Intake and output of matter and energy. 2. Achievement and maintenance of steady (homeostatic states. 3. Increase in order over time owing to increase in complexity and differentiation. 4. Extensive transactional commerce with the environment (Buckley, 1968). As other scientific disciplines began incorporating concepts of general systems theory, systems concepts were directed to living organisms. Ludwig von Bertalanffy, a biologist and integrative philosopher stated, "the beauty of systems theory is that it is psycho-physically neutral and its concepts and models can be applied to both material and non- material phenomena" (Laszlo, 1972 , p. 119). Bertalanffy attributed the further development of systems theory to himself and Burton. Their seminal writings in 1939 and 1940 led to the "theory of the Qrggnigm as an open system" (von Bertalanffy, 1968, foreword). By 1945, these writings had evolved into the development of General Systems Theory, an interdisciplinary doctrine "elaborating principles and models that apply to systems in general, irrespective of their particular kind, elements and forces involved" (Laszlo, 1972, p. xvii). The new paradigm or "new philosophy of nature" (von 16 Bertalanffy, 1968, p. xxi) introduced by General Systems Theory explores the general aspects, correspondence and isomorphism common to "systems" (von Bertalanffy, p. xix). Systems theory is frequently identified with cybernetics control theory. Cybernetics is the theory of control mechanisms in technology and nature and founded on the concept of the transfer of information between system and environment and within the system and control (feedback) of the system's function in regard to the environment. It is but a part of a general theory of systems; cybernetic systems are a special case of systems showing self-regulation (von Bertalanffy, 1968). fieneral.§x§tems_1heerx General Systems Theory can be divided into "three main aspects (realms). . .which are not separable in content but distinguishable in intention" (von Bertalanffy, 1968 , p. xix). The first realm is "systems science” which is scientific exploration and theory of "systems" in the various sciences (e.g., physics, biology, psychology, social sciences) and General System Theory as a doctrine of principles applying to all systems. The second realm is "systems technology" which is the problems occurring in modern technology and society including the "hardware" of computers, automation, self- regulating machinery, and the "software" of new theoretical 1'7 developments and disciplines. The third realm is systems philosophy, the re-orientation of thought and world view ensuing from the introduction of "system" as a new scientific paradigm (in contrast to the analytic, mechanistic, one-way causal paradigm of classical science) (von Bertalanffy, 1968) . The third realm of General Systems Theory, systems philosophy, is further divided into three components: systems ontology, systems epistemology, and systems relations. Systems ontology attempts to define what is meant by "system" and how systems are realized through observation at various levels. Von Bertalanffy divided systems into real and conceptual systems. Real systems are entities perceived in or inferred from observation, and existing independently of an observer, i.e. , a horse, a flower, a planet. Conceptual systems are symbolic constructs such as logic, mathematics or music. A subclass of conceptual systems, abstracted systems are conceptual systems supposedly corresponding to reality such as science. An ecosystem (or social system) can be viewed as a "real" system in that the changes or problems in the system can be felt (i.e. the ecosystem and pollution). However, the system cannot be directly observed and therefore an ecosystem could also be considered a conceptual system. Herein lies problems in system ontology of distinguishing physical and conceptual systems. The second component of systems philosophy is system epistemology, the study or theory of the origin, nature, 18 methods, and limits of knowledge in General Systems Theory. Since this involves the investigation of organized wholes of many variables, new categories of interaction, transaction, and organization are required. It is necessary to capture interaction within the system and be able to create labels for processes, rather than the use of linear causality reducationism and logical positivism. The third component of systems philosophy is systems relations, the concern with the relationship of man and world or philosophically termed "values". Within systems philosophy, the world of symbols, values, social entities and cultures is something very "real". Systems philosophy reflects an "embeddedness in the cosmic order of hierarchies 'two cultures' and therefore is apt to bridge the opposition of C.P. Snow's of science and humanities, technology and history, and natural and social sciences, or in whatever way the antithesis is formulated" (von Bertalanffy, 1968, p. xxiii). General Systems Theory provides a solution to a basic problem of modern science, a general theory of organization. It provides a foundation from which to define living system or social system concepts, such as organization, wholeness, directiveness and differentiation. "General Systems Theory is, in principle, capable of giving exact definitions for such concepts and, in suitable cases, of putting them to quanititative analysis" (von Bertanlanffy, 1968, p. 34). 19 "General Systems Theory, therefore, is a general science of 'wholeness' which up till now was considered a vague, hazy and semi-metaphysical concept" (von Bertalanffy, 1968, p. 37). One of the applications of General Systems Theory has been to the study of the family. Bubolz and Paolucci of Michigan State University applied the concept of ecosystem to the family (Andrews, 1980). An ecosystem is "the organism, its environment, and their interaction" . This provides a holistic way of viewing human systems such as individuals and families as a "set of components bound together as functioning wholes in dynamic interaction with the environment" (Andrews, 1980, p. 42). This ecological systems approach assumes that phenomena must be examined in their wholeness of interaction and interdependence, rather than by simple, ‘ linear cause- effect relationships. Using this approach, the goal of research is to identify patterns of relationships between systems and their environments, especially noting what happens at the interface. W "Family systems theory and associated therapy can be considered a logical step in development following the work of Sigmund Freud" (Kerr, 1981, p. 227). Freud's concepts were based on two basic ideas "that emotional illness develops in relationships to others, and the therapeutic relationship is the universal treatment for emotional illness" (Kerr, 1981, p. 20 221). These concepts laid the cornerstone for all individual theories, which remained the focus for fifty years hence. By the mid-1930's, psychoanalysis had gained acceptance as the method for dealing with mental illness. World.War II and its aftermath resulted in unprecedented numbers of people with mental .illnesses. ZPsychoanalysis, partially’ due ‘to its emphasis of post traumatic disturbances and partially because of its length and expense, proved ineffective in dealing with the numbers of people needing treatment. In addition, psycho- analysis was disappointedly ineffective with schizophrenics. Psychoanalysis with schizophrenics became the focus of experiments with various psychoanalytic therapeutic methods in search of new, more effective methods. The origins of family focus in psychoanalytic therapy was established by the early 1950's. Many therapist began to recognize that the family was somehow significant in therapeutic treatment, since most psychoanalysts had the experience of "curing" patients, returning them to their families, and witnessing the patient's regression into renewed symptoms. "This shifting focus from individual to family confronted these investigators with.the dilemma of describing and conceptualizing a family relationship system. During this period, family research with schizophrenia played a major role in starting the family movement, the development of family therapy, and the evolution of theory" (Kerr, 1981, p. 228). In the early 1950's, Murray Bowen, a psychoanalytic 21 psychiatrist, combined an interest in schizophrenia and the study of the family. He explored ways to better involve the family in the patient's therapy and improve outcome. He identified the mother-patient symbiosis or "emotional stuck- togetherness" as a natural phenomenon (undifferentiated family ego mass). While working at the Menninger Clinic, he hypothesized that "the mother's incomplete self incorporated the self of the developing fetus and was emotionally unable to give up the child in later years" (Kerr, 1981, p. 228). This hypothesis continued to reflect his underlying psychoanalytic emphasis on the individual as he began a research project in 1954 at the National Institute of Mental Health involving schizophrenic children and their mothers. This project focused on the mother-child relationship, and during the first six months Bowen's thinking about his observations underwent major shifts in conceptualization. Not only was the intensity of the symbiosis more fully seen, but the discovery that this mother-patient symbiosis was but a fragment of a larger family emotional system. "Concepts of individual psychopathology were being rapidly discarded as the schizophrenia of the person came to be viewed as symptomatic of a process involving the entire family" (Kerr, 1981, p. 229). Bowen reflected that his shift to family psychotherapy was not an easy one. "It was a shaking experience for me, long schooled in psychoanalysis, to become aware that psycho- analytic theory was not fact and psychoanalytic therapy was 22 just another method" (Kerr, 1981, p. 229). Bowen, along with other NIMH therapists, had to detach from individual theory and become more observant of family patterns, which involved a total retraining process. The therapy at NIMH could best be described as family group therapy, because the entire patient's family was seen as a group for therapy. In the period of 1955-1956, the family movement surfaced nationally, and Bowen's work with families brought much excitement as he presented the first family research paper in 1957 at the American Orthopsychiatric Association national meeting. Bowen described this period of launching the family movement as healthy, unstructured chaos. Enthusiasm for the family in therapy was met with conceptual difficulties inherent in moving from individual concepts to family process. Between 1957 and 1963, the thinking that ultimately became the basis of Bowen's Family Systems Theory grew rapidly. He focused on nuclear family process and the family projection process. Further family theory expansion came from his extension of a family concept of schizophrenia to a family theory that encompassed the full range of emotional illnesses. For example, he viewed the differences between psychoses and neuroses as W not mm, which, though controversial, evolved to placing all human functioning on a continuum known as the scale of differentiation (1960's) (Kerr, 1981). Other key concepts of Bowen's family theory developed in 23 the 1950's were: triangles, inter-dependent triad, multi- generational transmission process and sibling position. Along with nuclear family process and the family projection process, these six concepts were defined by Bowen as Family Systems Theory in 1963 and published in 1966. In 1975, he added two additional concepts, emotional cut off and societal regression. Based on these eight concepts, Bowen proposed family systems thinking as a new theory of human behavior. The primary goals of family systems theory are these tasks: "(a) A.description.of the unique organization characteristics of families; (b) An identification of the dynamic qualities of family functioning and family structures that help families regulate (pattern) the constancy of their internal and external relationships; (c) A description of family growth and development with.particular emphasis on the factors that make patterned growth possible" (Steinglass, 1987 p. 34). In summary, an evolution from systems theory to family theory has taken place. Wholeness, organization, and relationships, key concepts from systems theory, were applied to families or living systems. Families are unique systems in two ways: They are open systems and are capable of reproducing themselves. These two characteristics are of particular emphasis in the application of general systems theory to living systems and resulting in family system theory. In conclusion, the principles of systems theory are the 24 foundation or meta-theory of marriage and family theory. Dr. Al DeVoogd operationalized marriage and family theory into the Trimodal Meta-Model, which he feels can encompass all systems based theories. The Trimodal Meta-Model defines productive (healthy) dyadic interaction through identified patterns of interaction skills that result in productive outcomes. DeVoogd has developed a coding system based on his meta-model which is the focus of this research. Major Schools of Marital and Family Therapy Theory Given the prior presentation of the history of marriage and family therapy, it is not difficult to understand that theories are as varied as its beginnings. From traditional psychoanalytic theory to learning theory, marital and family therapy theory is not monolithic. Kaslow (1981) has detailed nine approaches that represent the major theories of marital and family therapy: psychoanalytic, Bowenian, contextual- relational, structural, strategic-systemic and behavioral. (Kaslow introduces dialectic theory as a tenth theory, one which is integrative of the other nine theories). Kaslow (1981) developed two models to present the nine theoretical perspectives in reference to their perspective of time (Figure 1) and their theoretical focal points (Figure 2). In each figure, Kaslow placed an over-riding arch to represent a tenth approach to theory, which she has labeled "dialectic" or integrative theory (Kaslow, 1987, p. 840). 25 . Integrative Diaclectic Multlmodal 1 Emphasis on present emguu amuwaaumums moss: moutandpreeent lrlll l Psychoanalytic Sowenian Contextual Experiential Strategic Structural Communication Behavioral ... Figure 1: Kaslow's Model - Nine Theoretical Perspectives and Their Perspectives of Time .. Integrative Diaclectic Multimodal Both dimension: of equal 1 Intrepsych ic import to tnmgnt Interpersonal ‘-——‘* —-> Psychoanalytic Bowenian Contextual Experiential Strategic Structural Communication Behavioral Figure 2: Kaslow's Model - Nine Theoretical Perspectives ,and Their Theoretical Focal Points Among these nine theories, certain commonalities exist. Systems theory can be demonstrated in all nine theoretical perspectives. All theories stress assessment as an important first phase of therapy, although the approaches to assessment vary from actively intervening and observing the effect of the intervention on the system to a thorough, systematic assessment. Ail theoretical schools share a belief in the importance of certain. mediating' goals in 'therapyu .All therapists consider the recognition and modification of the communication patterns. Although different paths may be taken, all theoretical perspectives seek some similar outcome. 26 The following are those that are recognized as important by all: development of role flexibility and adaptability, a balancing power, particularly in marital therapy; the establishment of individuality within the family collectivity; and greater clarity and specificity of communication (Kaslow, 1987, p. 840). Historically, Psychoanalytic Family Therapy is the nearest descendant of individual psychoanalytically oriented psychotherapy. Nathan Ackerman, psychoanalyst and child psychiatrist, was an early leader who published "The Unity of the Family" in 1938. In 1965, he founded the Family Institute of New York in response to the interest in his work and as a therapist training center. The psychoanalytic group first developed the family-history taking as it adhered to the belief that unconscious factors and one's past history play an important role in present behavior and symptomatology (Kaslow, 1987, p. 841). In treatment, assessment plays a central role. There are many ways of doing assessment, with primary focus on interactional themes. All members of the family unit, as well as the relationship between and among them, are considered the patient. This View point reflects systems theory (as the meta-theory). 27 WW Bowen's approach was clearly related to systems theory as reflected in his statement, "the successful introduction of a significant other person (i.e. , the therapist) into an anxious or disturbed relational system has the capacity to modify relationships within the systems" (Kaslow, 1987, p. 842). Bowen put much effort into eliminating "transference", the assumed that and assigned importance of the therapist, in order to ensure the intensity of the relationship would be centered on the original family members and not siphoned off into an intense transference relationship (Kaslow, 1987, p. 843). Bowen and his colleagues stressed the concept of the "differentiation of self" (the degree to which individuals are able to distinguish between the feelings process and the intellectual process). Herein lies the crux of Bowenian theory. In treatment, the therapist supports the individual efforts, so that if the person is sufficiently motivated, he/she can differentiate from the family of origin while not becoming overly fused with the therapist. Problems are reframed, emotional work. with the family of origin is encouraged and coached, needs and desires are clarified, and increased reciprocity and cooperation fostered. This process of differentiation is probably never fully completed, so the overall treatment goal is positive differentiation. Ivan Boszormenyi-Nagy, a psychiatrist, originator and leading proponent of contextual family therapy, established his reputation through his work with families at Eastern Pennsylvania Psychiatric Institute in Philadelphia. Here he wrote W with James Framo in 1965, which reflected a traditional psychoanalytic approach to family therapy. In 1973, he co-authored W with Geraldine Spark, emphasizing one's indebtedness to family of origin; the profound influence of one's own biological relatedness; and, the conceptualization of an ethical- existential framework. In treatment, the family is viewed as dealing with a sense of hurt and unfairness on the part of a member or members. The family ledger is imbalanced and a corresponding breakdown of trust exists. Stagnant relationships and few resources for trust building result, as well as a sense of unfairness in the family. Assessment involves a three generational genogram which the therapist uses to assess fairness and its violations between family members. This assessment's importance is both its content and process, as it serves as a trust building vehicle between the family and the therapist. The therapist's role revolves around the multilateral nature of the issues; acknowledging this and conveying this to each individual, thereby establishing trustworthiness with the family. This process is 29 known as "multilaterality", a commitment to a fair balance of give and take, and a process of re-engagement in living mutuality. Contextual-Relational Family Therapy and Theory reflects systems theory in its use of the family of origin as a system impacting both the individual and the individual's relationships with his/her current family and also demonstrates an open system adapting to input. (Kaslow, 1987, p. 844-845). The main personality behind experiential therapy is Carl Whitaker, a psychiatrist who experienced working with severely disturbed patients, including schizophrenics, in a mental hospital. He began exploring the nature and utility of "craziness", the need to allow one's own unconscious to intuitively enter the world of the patient and the importance of harmony between the therapist's style and nature. In 1950, he began practicing and writing about family therapy and along with his colleagues, Warkentin and Malen, experimented with co-therapy. By 1960, he moved to the University of Wisconsin Medical School, taking a position at the Department of Psychiatry. He was a pioneer in teaching family therapy to residents. His therapy is characterized by his warmth, playfulness, sense of humor, genuine compassion, intuitive giftedness and keen knowledge of people. When training 30 others, he encourages them to try to copy his style, but explore and develop their own style. Symptom relief is not the focus of this therapeutic style, since the symptom is believed to be an adaptation and "an exquisite experience of regression in the service of the ego" (Kaslow, 1987, p. 845). Therefore, it cannot be abandoned until the patient perceives it as too weighty and no longer necessary. Whitaker developed the use of paradox as a means of symptom prescription which exacerbated the symptom to the point of it toppling under its own weight. Whitaker believes that therapy must be an authentic encounter for all involved as the experientialists, through family therapy, make a deliberate attempt to heighten anxiety in the family. Then, through mutual support of a co- therapist, the therapists play many roles allowing the family members also to engage in role exchange. Through caring, the therapeutic team supports the family so they can risk becoming more anxious and begin to open up their own zany and idiosyncratic inner world (Kaslow, 1987, p. 846). The use of the person of the therapist and the family in therapy both demonstrate a view of family therapy based on systems theory. (Kaslow, 1987, p. 845-847). O . II II I A . — - ‘ - . - _ I - - O ‘ O - . o o . v o ,0 O I , v o o . . w ‘ . .. -.. . . . - , . _ _ -.-.4 . -, ...-4 .. .. This theory grew out of the 1950's research work of Gregory Bateson, Don Jackson, John Weakland, Paul Watzlawick 31 and Jay Haley in the area of communication process. Primarily working' with schizophrenics, they' blended their diverse backgrounds and applied anthropological methods of participant observation and objective scrutiny, as well as social systems theory to their work. In 1959, Jackson, a psychiatrist, established the Mental Research Institute and then was joined in 1962 by Jay Haley and Virginia Satir. In her family therapy primer, W (1964), Satir outlined the core ideas of the communications wing of family systems, theory and therapy (Kaslow, 1987, p. 847). Together the Palo Alto group formulated the concept of the double bind based on their research on communication patterns in schizophrenic families. (The double bind being a set of contradictory messages sent by the family, i.e., damned if you do, damned if you don't). Jackson coined the term "family homeostasis" to describe the process in.which.the family desperately attempts to maintain status quo. Satir developed and contributed the concept of family sculpting, a.process by which people depict how they view their family without the use of words filtered through secondary-process thinking. Jay Haley contributed his interest in the use of paradox to disrupt rigidified relational and communication patterns and in 1962 he became the first editor of £amily;£zgge§§, the first journal devoted entirely to family theory and therapy. The Mental Research Institute staff also pioneered the brief family intervention and crisis techniques (Kaslow, 1987, p. 847). 32 The communication therapist is an active interventionist who directs and structures the sessions and places a high value on clarifying communication. Interventions used are manipulating the environment, assigning "homework" or tasks, and challenging the family's beliefs. Assessment is not standardized and it is concerned with specific problem behaviors, which are deemed to be metaphors for the basic thematic interaction patterns. The original problem is viewed as a statement about power distribution and conflicts in the family, while treatment focuses on the W between members. End goals include replacing stereotypical role concepts and behavior with greater breadth and flexibility, seeking resolution of the presenting difficulties, redistributing power for a more equitable balance, and enabling the participants to communicate more clearly and accurately what they think, feel, and desire. Systems theory is reflected in Communicational-Interactional Family Therapy and Theory through the use of the family system in treatment and the goal of improved communication and re-distribution of power in the family. WWW Salvadore Minuchin, a Argentine physician, worked in Israel and then practiced pediatrics and studied child psychiatry in the United States (Kaslow, 1987, p. 848). He 33 became involved in the Wiltwyck School in New York and studied the structure and process of the interactions of families of low socioeconomic status who produced delinquent children. This work shaped structural family therapies basic tenets: family structure and boundaries, the concept of subsystems and the importance of observing the process of family communication and intervening to disrupt faulty messages (Kaslow, 1987, p. 848). Structural therapy is based on the concept of perceiving people as a part of their environment, interacting with rather than acting on it. This is the context or the circumstantial reality and determines how one experiences the world. Structuralists feel it is essential to focus on the here-and-now, because what was important about the past is re-enacted in present transactions and is visible in the therapy session and the current behavior. A central tenet is the notion of hierarchical organization within the family. A family should not be a group of equals, instead it is a group of subsystems with boundaries contingent on constructing or reinforcing the appropriate boundaries. Using a brief therapy approach of 5-6 months, the task of therapy is to restructure the family, introducing to the members alternate ways of interacting. The therapist believes that the family has the capacity to adopt new patterns of behavior and/or interaction and to change in the direction of more adaptive functioning. The therapist rapidly joins the family, collects data and diagnoses the problem. The 34 presenting problem is accepted as the real problem and interventions are designed to relieve the symptoms and in so doing, to improve the systemts functioning. The therapist is a conductor, active and powerful, who conveys his/her expertise in his/her own abilities to assist the family to mobilize their capacity to change. Structural theory views the family as a system able to benefit from the therapeutic experience in a process of adaptation (Kaslow, 1987, p. 850). This theory has commonalities with communications and structural theories: focus on the present and the interdependency of the members of the family system. The family is viewed as nonsummative; it is more than the sum of the individual personalities and includes their interactions. Jay Haley fashioned strategic family therapy from communication and cybernetic theory and Erickson's innovative use of hypnotic and unorthodox, meta-cognitive therapeutic techniques (Kaslow, 1987, p. 851). In the late 19708, Haley and.Madanes left their positions at the Child Guidance Clinic in Philadelphia and founded the Family Therapy Institute of Washington, D.C. , where strategic family therapy is taught and practiced. About the same time, in Galveston, Texas Robert MacGregor, Harold Goolishian, Alberto Serrano, and their colleagues charted the path in devising multiple-impact family 35 therapy, working as a team with out-of—town families for several consecutive days. In the late 1970's the Galveston Family Institute emerged as a training and treatment site, and in the early 19803 they became involved in the new epistemology, cybernetics, recursiveness, and the work of Humberto Maturano (Kaslow, 1987, p. 851). Another group of theoreticians and clinicians known as the Milan Group is headed by Mara Selvinia-Palazzoli. Also in Rome, is the Family Institute under the leadership of Maruizio Andolfi, who created "provocative therapy", in which he confronts the patient early in the session, literally provoking a strong reaction to unfreeze the existing dynamics and structure (Kaslow, 1987, p.851). In strategic therapy, the clinicians overtly assumes their responsibility for influencing the patients and maximizes their power in order to effect change. Family system change is perceived to be essential as a forerunner to individual change. The therapist takes deliberate forceful steps to change enough facets of the repetitive pattern so that the symptom will no longer be needed and will wither away. Diagnosis is made based on the observations gleaned when an intervention is made and the family member's reactions are noted. Traditional diagnostic labeling is avoided; however, the focus is kept on the index patient, thus going with the family's definition of the perplexing situation. As in behavioral therapy, the major therapeutic tools are tasks and 36 directives. Therapeutic change comes about when new interactional modes are triggered by the therapist's direct and active interventions in the family system. There are two levels of change, W entails minor modifications that may change the system or its members in ways that may be seen as appropriate and "significant", and W which results from major modifications in the interaction and transaction patterns and can result in rapid, non-logical, system changes. Symptom prescription, paradoxical instructions and reframing are intervention techniques used in this therapy. Strategic-systemic family theory reflects its basic ties to systems theory in its use of the family system and its ability to make first and second order changes by adapting to therapeutic interventions (Kaslow, 1987, p. 852). The behaviorist attempts to look at behavior in relation to the environment which, in turn, leads to the definition of a cause or causes associated with the presenting problem. Social-learning theory, cognitive-behavioral and rational- emotive theories and therapies all fall under the heading of behavioral theory and therapy. Behavioral theory utilizes the systems concept. Liberman, a proponent of behavioral therapy, believes that it is misleading to regard one person's behavior 37 as the cause of another's behavior, without considering the reciprocal contribution made by the other person. One's behavior is maintained through reinforcement by another and control is therefore a circular or reciprocal process. Behavioral therapists stress the learning or relearning of ways to relate and use "contingency contracting", communication skills training and the application of reinforcement principles to increase positive relational behavior. Behavioral therapy is both a method of inquiry into clinical problems and a body of intervention strategies. Along with assessment and treatment, the establishment of a positive working alliance with the couple or family is stressed. Central to this theory is the tenet that these patterns and all other recurring behaviors are rewarded in some manner or else they would not be repeated. Through positive teaching, the therapist emphasizes the positive aspects of the particular relational system. Positive behavior changes is emphasized through the use of positive reinforcement rather than punishment or negative reinforcement. The concept of reciprocity is integral to the behavioral approach, there is a give and take between two persons interactions. The therapist acts as a teacher and educates through modeling, didactic training, reading sessions and other specific homework. This mode of therapy continues to grow in popularity, largely because of the clearly delineated, widely applicable techniques that continue to be 38 generated from research on human relational behavior. Behavioral and problem solving theory utilize systems concepts through the use of reinforced behavior in the family system and the systems ability to adapt to more functional levels of behavior through the teaching therapist. It is a model that lends itself well to psychotherapy outcome research (Kaslow, 1987, p. 853). The move from a psychoanalytic to a systemic focus of therapy opened the doors to the observation of family interaction. In 1926, Ernest W. Burgess wrote a paper entitled "The Family as a Unity of Interacting Personalities" . Thus began the research interest in the family as a context for interaction rather than as an institution (Touliatos, 1990). The research on interaction has a specific goal to "contrast functional and dysfunctional groups rather than to develop normative data about families" (Markman and Notarius, 1987, p. 333). Along with research on the observation of family interaction came the development of coding schemes. "Techniques for behavioral coding of marital and family interactions have been with us for some twenty plus years" (Weiss, 1989, p. 242). In 1955, the collaborative work of Talcott Parsons and Robert Bales yieled the IPA or Interaction 39 Process Analysis, an observational coding system for analyzing group process in M problem-solving groups. "Both the methodology and the key variables assessed (in IPA) provided the basis for numerous coding systems that were developed over the next twenty years, aimed at assessing the problem-solving and naturalistic interactions of disturbed individuals and their families" (Jacob, 1987, p. 8). By 1970, Olson and Ryder had developed the MFICS, Marital and Family Interaction Coding System, which was a descriptive non-theoretically based coding scheme that was developed for coding marital interaction. This was "the first study using observational methods to investigate marital interaction.. ." (Markman, et al, 1981 , p. 242) . Coding schemes have become more specialized as seen in this expansion of focus from group interaction to marital interaction. Specific to the coding analysis of marital interaction is the focus on the'dyad. In 1942, Becker and Useem presented this definition of the dyad: "Two persons may be classified as a dyad when intimate, face-to-face relations have persisted over a length of time sufficient for the establishment of a discernable pattern of interacting personalities" (Thompson, 1982, p. 890). Thompson and Walker (1982) explored the conceptual and methodological issues in research using the dyad as the unit of analysis. They concluded with two mandates for family researchers regarding dyadic study: "clarity about conceptualization of the pattern between 40 partners and consistency about the relationship pattern at every stage of the process" (Thompson and Walker, 1982 , p. 898) . Poole and Folger (1981), in their article "Modes of Observation and the Validation of Interaction Analysis Schemes", review the purpose for constructing a code scheme. They relate Lazarsfeld and Barton's (1969) classic work on the construction of coding categories which argues that "the purpose of coding schemes is to allow the researcher to systematically and rationally reduce the complex set of attributes which is more tractable" (p. 482) . In their View, a coding scheme reduces a complex set of attributes, yet still captures the phenomenon adequately for the researcher's purposes and does not confound nor distort dimensions of the phenomenon which are important to explaining or understanding it. A coding system does not have to represent every variable in the interaction, rather it has to code accurately those aspects of interaction it is designed to code. According to Markman and Notarius (1987) , there are three primary agendas confronting the family interaction researcher: 1) establishing the research situation; 2) coding the interactional data and 3) extracting meaning from the coded interaction. These three agendas will provide the structure for the remainder of this research review. In order for the researcher to observe marital interaction, choices must be made as to the task, setting and 41 recording of the interaction. Given the expense of observation research, laboratory situations are usually structured to increase the chance that the behaviors of theoretical interest are displayed. Researchers may choose a task to generate interactional samples (Gottman, Markman and Notarius, 1977), or observe families with minimal external structure imposed (Patterson, 1981). As noted by Cromwell, Olson, and. Fournier (1976), the tasks used. to generate interaction fall into four categories: problem-solving, decision-making, conflict-resolution, and. naturalistic. Because the task effects the family's interaction (Gottman, Notarius, Markman, Bank, Yoppi and Rubin, 1976), these effects must be considered when generalizing beyond the situation studied. As reflected by Levenson and Gottman (1983), "the demand associated with laboratory experimentation extract significant compromises that may escalate until the experimental context bears little relation to natural dyadic interaction" (p. 587). The choice of live observation versus recordings depends on the complexity of the coding system. Trujillo (1986) delineates four types of recording devices: fixed forms, still photography, audio recordings, and chronographs. Fixed forms range from blank paper to very specific coding forms, while chronographs are sophisticated devices that often partially process the data while recording it. The more complex the coding system, the greater the need to have a 42 permanent interactional record. "The most important tool necessary for the coding task is the catalog of interactional behaviors that will be judged, rated, or scored; in short, the code book” (Markman and Notarius, 1987, p. 334). The code book specifies the categorization of each behavior in the ongoing interaction stream. The operationlism of each interaction behavioral dimension from individual codes can be arrived at in four ways. First, common codes are identified, combined and factor analyzed to establish which codes are related (Gottman, 1987) . Second, codes are assumed to define a given conceptual dimension and lumped together. Third, if coders are unable to distinguish between codes, the categories may be combined. Fourth, instructions may be given to code directly a dimension of interest to the researcher. This approach requires coders to make global judgements about dimensions and it is not always clear what the behavioral referents are that the coders are using (Markman and Notarius, 1987). Comprehensiveness and validity are also two aspects of developing a coding scheme. Comprehensiveness in coding implies that the coding system is able to handle the breadth of the dimensions being coded. Validity implies that research accurately measures what it claims to be measuring. When 43 coding systems are being are being designed, another decision to be made is the unit to code. The coding unit enables the researcher to segment or reduce the stream of interactional behavior into analyzable units. Common units used in assessing marital and family interactions are the unit of observation and the unit of measurement (Floyd, 1989). "The unit of observation refers to the element of behavior, within a particular context, that is actually being observed. The unit of measurement refers to the record of the behavior produced by the observer" (Floyd, 1989, p. 14). The unit of observation and unit of measurement at times may be the same or different. Further distinctions in coding units can be qualitatively made as between molecular versus molar behaviors (Cairns and Grass, 1979) . These terms can distinguish between the size of the coding unit and the complexity, or dimensionality of behaviors assessed (Floyd, 1989). Coding units range in size "from the smallest unit, the 'act', defined as a simple grammatical sentence expressing a single idea, to the 'speech' or 'floor switch', defined as everything spoken until another person starts to talk, to the 'idea' defined.as all speech.that.makes up the presentation of a single idea and to the 'theme’, defined as a large black of interaction dealing with a global theme" (Markman and Notarius, 1987, p. 335). Another consideration in developing a coding system is the data type. The data type, either event or timed, is derived 44 from the boundary between coding units. Event-based data types are coding units that range from "act" to the "theme" and.result in data such.as "rate per'minute". Time-based.data produce rates-per-time, with the selection of a specific time unit, such.as a minute or ten minute segment. In the analysis of marital interaction, one of the two most popular systems uses timed coding units, the Marital Interaction Coding System (MICS) and the other is event-based, the Couples Interaction Scoring System (CISS). Whether to use event or time based data depends on the type of coding used, the task, and the purpose of the investigation (Markman and Notarius, 1987). Data analysis, the task of extracting meaning from strings of codes, is the next task faced by the researcher; There are two basic data analysis strategies: non-sequential and sequential. Non-sequential analysis occurs when comparisons are made, frequencies are gathered or length of duration is noted. "Much of the richness of social interaction is lost when analysis is limited to an.examination.of the frequency or the rate with which each code occurs: (Markman and Notarius, 1987, p. 338). Therefore, sequential analysis is preferred, as it allows the researcher to track ongoing stimulus-response patterns that characterize the interactional system. Cod' S As the trend toward measuring behavior rather than 45 attitudes grows in the area of family studies, observational studies marital interaction are increasing. There is a need for better diagnostic and assessment techniques in therapy, as the belief increases that marital distress arises from dysfunctional patterns of interaction between the spouses (Filsinger, 1983). Beginning in 1980, several articles were written reviewing marital dyad interactional coding systems. In 1983, Filsinger compared five marital coding systems, noting their strengths, weaknesses and recommendations for clinical use. The systems reviewed were: Weiss's Marital Interaction Coding System (MICS), Gottman's Couples Interaction Scoring System (CISS), Filsinger's Dyadic Interaction Scoring Code (DISC), Olson and Ryder's Marital and Family Interaction Coding System (MFICS) , and Raush's Coding Scheme for Interpersonal Conflict (CSIC). He concluded that the researcher/therapist must identify the coding system that best suits his/her needs, in addition to considering the system's operational cost and time needed for observing and coding. "Even without the full use of the entire coding procedure, knowledge of the coding systems may help clinicians become more sensitive to important behaviors and patterns in the couples and families they see" (Filsinger, 1983, p.332). Markman and Notarius (1987) reviewed twenty marital and family coding systems in "Coding Marital and Family interactions" . The Marital Observation Coding Systems covered 46 were Couples Interaction Scoring' System (CISS), Marital Interaction Coding System (MICS), and Kategorien system For Partner-Schaftliche Interactions (KPI). The review of each includes history and objectives, codes and dimensions, coding process, reliability and validity, relation to core dimensions and commentary. In conclusion, these writers comment that research has taken two basic approaches to identifying the proximal determinants in psychopathology of family members. One is to assess only one or two dimensions, sometimes using global coding of interaction. Second is the comprehensive microanalytic study of the interactional stream to identify behaviors associated with functional or dysfunctional interaction. They foresee that the next generation of marital interaction coding systems will "incorporate previous research findings into new systems coding larger units of interaction" (p. 379). Caveats to moving to more global coding are presented, Markman and Notarius express, "there is a paucity of specific coding systems that explore the role of family interaction and affective disorders, psychophysiological disorders, subclasses of schizophrenia, and personality disorders” (p. 380). In 1989, two new global coding systems were introduced. Krokoff, Gottman and Hass reported on their development of a new global rapid marital interaction coding system in their article, "Validation of a Global Rapid Couples Interaction Scoring Systemfi. The RCISS identified a set of communication 47 skills and deficits in problem solving that differentiated satisfied from dissatisfied couples. Julien, Markman and Lindahl announced their new global coding system the IDCS, in their article, "A Comparison of a Global and a Microanalytic Coding System: Implication for Future Trends in Studying Interactions" (1989). However, since the IDCS was normed on premarital couples, the authors cautioned interpretation of results, as there occurred much less variance in relationship satisfaction than is usually observed in marital studies. In 1991, Gottman received an award from the American Association of Marriage and Family Therapists acknowledging his research which predicted the longitudinal course of marriages. This research was first published in 1983 under the title of "Marital Interaction: Physiological Linkage and Affective Exchange". Gottman. was able to predict the longitudinal deterioration of marital satisfaction based on the physiological arousal of the couple, particularly of the husband. In searching for the link between deterioration of marital satisfaction and later separation and divorce, Gottman began another study in which he developed a facial coding system. Using this system, he was able to predict marital separation and divorce. The development of a facial coding system and the use of physiological feedback are historic firsts in the area of marital interaction coding systems. 48 As noted by Filsinger (1983), one of the criticisms of marital observational coding systems is that "the practitioner is unlikely to have the resources necessary for coding interaction and producing useful data quickly enough to use in the course of therapy" (p. 223). Even considering the most recent work in the field, all codes rely on the use of recordings to be coded later and are primarily utilized to gather data for research rather than being useful to the clinician. Weiss (1973) states that "assessment and intervention are two sides of the same coin" (p. 312). Since marital interaction coding systems identify or assess the present state of the marital relationship, it would be most useful if they could also be used to plan interventions. However, this has not been the case, since they are research focused and the clinician may not be involved in the evaluation of the data. Nor is there mention in the literature about any efforts to take the coded material to the clinician to plan interventions. Schumm is critical of the isolation between theorists, researchers and clinicians in the family studies area. He says that a circular system in family research exists between family theory, measurement and statistical analysis. He calls for the integration of these components of 49 family research instead of isolation. As further marital interaction coding systems are developed, the interaction of this circular system could broaden and strengthen family studies. Trimodal: A Meta-Model for Understanding Productive Dyadic Interaction The Trimodal, which forms the basis of the research component in Chapter III, was developed and copyrighted (1975) by Albert DeVoogd, D. Min. , co-founder and senior therapist at the Marriage and Family Center of Grand Rapids, Michigan. Through his study of dyadic interaction, as both a minister, missionary and marriage and family therapist, DeVoogd developed Trimodal to define productive (healthy) dyadic interaction. He has used it extensively in his practice and, over the years, has trained numerous marriage and family therapy interns and clinicians in its use. DeVOogd's inception of Trimodal began in his early years as a missionary to the Chloe people of Chiapos. He sought to define the commonalities of skills that defined productive human interaction. With a degree in ministry, an anthropological perspective and a sense of wonderment, DeVOogd's gifted intellect crafted his observations of people's interactions into Trimodal. He sought to define the commonalities of skills that defined productive human interaction. 50 Based on his observations, he saw that people related in three modes of interaction; identity affirmation, needs contracting and problem solving. The values of each are follows: (1) identity affirmation, the value of the infinite worth of the individual; (2) needs contracting, the value of integrity and mutual satisfaction relationships; and (3) problem solving, the value of co-creative and collaborative teamwork. .After returning to the United States, from.his missionary work in Chiapos, DeVoogd began formal training in the field of marriage and family therapy. He and Andrew Atwood were instrumental in founding the Marriage and Family Center of Grand Rapids in coordination with Central Reformed Church. DeVoogd mentored Atwood in his evolution as a therapist, as he did many of the therapists who would come on staff at the Center. DeVoogd saw Trimodal as a definition of outcomes sought by marriage and family therapists in their work with individuals, couples or families. He was insistent that all who came to him for training be able to speak the language of Trimodal. Although the creation of Trimodal came prior to his formal therapy training, DeVoogd retrospectively was able to see connections between his model and the existing theories of family therapy. In relation.to systems theory, be viewed the dyad as the smallest system of analysis in his model and was able to define larger systems in therapy in terms of dyads. 51 He felt that by using the dyad as the unit of analysis, the therapist was able to clearly observe productive and nonproductive interaction. When discussing the three modalities, and how they related to current family therapy theory, DeVoogd saw the following parallels. He felt the Identity Affirmation. mode was reflective of Object Relations Theory developed by Fairbain who postulated that "man's need for a satisfactory object relationship constitutes the fundamental motive for life." (Gurman, 1981, p. 137). The skills of this modality are markers for productive interaction with that "object": to which one desires a relationship. In the Needs Contracting mode, a parallel can be drawn with the theory of Transactional Analysis. In Transactional Analysis, the roles of parent, adult or child are played out between two individuals in hope of experiencing a productive relationship. Through the expression of one's own needs, the individual hopes to experience a commitment with another person for meeting one another's needs. DeVoogd was a strong supporter of social learning theory (Bandura, 1977). He integrated Millon's three levels of dysfunction (mild, moderate and severe) into his training of therapist. This provides the therapist a means to determine whether individual is necessary instead of or in addition to marital therapy. He believed that dyadic interaction problems sometimes arose because participants lacked skills and 52 abilities to problem solve. In these cases, he felt it was possible to train or model these behaviors for clients or provide them with information. At this point, it is important to remember that DeVOogd developed Trimodal prior to formal study or training in Marriage and Family Therapy. His effort to relate his model to existing theory was probably more driven by the needs of those he mentored than his own. This is evidenced by his belief that what he had created was £191; a theory, but a vehicle for the therapist to define the therapeutic outcomes they sought through the use of different theoretical models and related techniques. Upon first inspection, Trimodal appears rather simplistic and therefore very attractive as a training tool for novice marriage and family therapists. It provides a set of observable skills that define productive diadic interactions. Here lies the beauty of Trimodal. Because the skills are observable, as defined.by the model, the student is also given a means by which to assess, evaluate and measure progress in therapy by definable skills. As training in use of Trimodal evolves, the underlying intricacies of the model unfold. DeVoogd closely followed the work. of Theordore Millon, an authority in the area. of psychopathology and developer of the Millon Clinical Multiaxial Inventory (MCMI). DeVoogd was astute in his understanding of individual personalities and dysfunction. 53 DeVoogd's model defines what is relevant to observe, how to conceptualize what is observed and how to formulate a "treatment plan" (Beerthuis, 1991, p.5). The model provides a context for examining two relationship interaction components: (1) content (communication), defined as the semantic value of behavioral (verbal and non-verbal) content and (2) process, defined as behavioral patterns of linkage that establish and maintain relationship interaction (Beerthuis, 1991). The Trimodal is based on five assumptions: 1.) All transactions are analyzed as dyadic interactions. 2.) Three primary modes of interaction comprise the dyadic system available for analysis. a. The first modality of dyadic interactions define and affirm individual identity. The dyadic interaction outcome is the formation and affirmation of individual identity. b. The second modality of dyadic interactions meet personal emotional needs of both of the dyadic components. The interaction outcome is personal and emotional needs are met within the dyad. c. The third modality of dyadic interaction resulting in productive work. 3.) The three interaction modalities can be defined as 54 skill sets of: a. Identity Formation and Affirmation b. Needs Contracting c. Problem Solving 4.) The life development process is movement toward fulfilling the three interaction outcomes through relationship skill mastery. 5.) Personality can be defined as a set of coping strategies based on personal traits and characteristics directed toward the fulfillment of three interaction modalities. W The following model tenets are delineated by DeVoogd: 1.) The primary relationship dyadic interaction can be defined and analyzed from the perspective of a secondary dyad (Therapy). 2.) The productive dyad will demonstrate a well defined set of skills in interaction modality usage at the relationship interface (Process level 3). 3.) The productive relationship dyad will demonstrate a flexibility in interaction modality selection for patterns of interaction with the dyad (Dysfunction). 4.) The productive relationship dyad will have a well defined pattern of consensual validation in communication transactions (Consensual Validation). 55 5.) The productive relationship dyad. will have a well defined pattern of meaning thrusts that are congruent with the consensus of prior transactions in the communication sequence (Continuity of Meaning). 6.) The productive relationship dyad interactions will have a well defined pattern of contextual congruence in relationship transactions (Contextual Congruence). 7.) The persons in a productive relationship will demonstrate, as under their control, a rhythmic movement across a continuum from a point characterized as individual uniqueness demonstrated by autonomous actions to a point characterized as oneness, union and fusion demonstrated by interlocking behaviors (Relationship Evaluation). W The Trimodal is comprised of three interaction modalities, including Identity Affirmation, Needs Contracting and Problem Solving (see figure 3). Each modality delineates a set of measurable skills that define productive interaction in that modality. The dyadic interaction is analyzed as to its demonstration or lack of demonstration of these. 56 air—___ —- —— -—-- —- ,Mfi_ IDENTITY AFFIRMATION NEEDS CONTRACTING ,__ ___ _,,,~ .7 fifi-__.__ _ ___.A— ___—___- _. ___ __ _ flil_. 7,, , _ ,7 l ‘ A . ._ PROBLEM SOLVING I i I J i i l l l t‘. ___ ._ _ _--‘H__‘ __ __ ___, ____ _ __ , 77,- _ ¥ _ __ .1 Figure 3: The Trimodal Modalities (DeVoogd, 1993) The Identity Affirmation modality is comprised of skills related to identity definition and affirmation. This subsystem emphasizes the worth of the individual, and the skills it involves are: self awareness; self disclosure; awareness of the significant other, and; acceptance of the significant other. When used productively, the skills of self awareness and self disclosure elicit from the relationship partner awareness of the significant other and acceptance of the significant other (see figure 4). 57 IDEHIIIIIX_AIEIBMAIIQH Self Awareness Awareness of Others Self Disclosure Acceptance of Others i W Delineation of a needs system Delineation of specific needs Acceptance of needs system Commitment to meet need 3. 4. 5. EBQBL§M_§QLEIH§ Definition and Commitment to Identification Selection of a Implementation Evaluation. Figure 4: ownership of problem by sender. joint ownership by receiver. of possible options. course of action. of course of action. Skills of Trimodal The Identity Affirmation subsystem "is characterized by the interaction patterns of the two unique personal entities interacting without overlap" (DeVoogd, 1993, p. 3) (figure 5). 58 Identity Affirmation Needs Contracting Problem Solving O O O O O 6'. .0 °e 0. 9:6 0 e e 0 6.0 0.9 9’0 0‘0 O .O O O '0 .O .O O O O e e O a e O O O O O O .9 O O o e .0 e .0 e see 00 \‘O. e O. O O O Figure 5: Relational Position of Dyad in Each Modality Needs Contracting modality is comprised of skills related to meeting personal needs. This modality emphasizes the inherent demand for integrity in needs contracting. The skills it involves are: the delineation of a needs system, the delineation of a specific need, the acceptance of a needs system and the commitment to: meet the need. When used productively, the skills of delineating a need system.and the delineation of a specific need elicit from the relationship partner an understanding acceptance of the need system and some level of commitment to meet. the need (figure 4). This 59 modality "is characterized by behavioral patterns of interdependency of the two personal entities. It is represented as the partial overlap of two interdependent personal entities at the point of their need system" (DeVoogd, 1993, p. 3). (See Figure 5). The Problem Solving modality is comprised of skills related to socially acceptable work. This modality emphasizes that work is a valid social contribution. The skills it involves are: definition and ownership of a problem by the sender, commitment to join ownership by the receiver, identification of possible options, selection of a course of action, implementation of a course of action and evaluation (see Figure 4). This modality "is characterized by the integration of the dyad into a working unit in the production and consumption of wealth. It is represented as persons in a relationship overlapping in forming a socially acceptable work unit. The productive relationship dyad will be productive of socially acceptable work as a social contribution" (DeVoogd, 1994, p. 4). (See Figure 5). W DeVoogd developed the following set of three tenets to define healthy, productive interaction based on the Trimodal Meta-model: 1.) The productive dyad.will demonstrate a.well defined 60 set of skills in interaction modality usage at the relationship interface. 2.) The persons in a productive relationship will demonstrate, as under their control, a rhythmic movement across a continuum from a point characterized as individual uniqueness (demonstrated by autonomous actions), to a point characterized as oneness, union, and fusion (demonstrated by interlocking behaviors). 3.) The productive relationship will demonstrate a flexibility in interaction with the dyad (Beerthuis, 1991, p. 10). - c ti Non-productive or dysfunctional interaction can be evaluated from both a process and content orientation. Using the demonstratable skills of the three subsystems, Devoogd states a working hypothesis that "a process baseline in interpersonal interaction behaviors can be established for the evaluation of productive versus non-productive relationship behaviors" (Beerthuis, 1991, p. 9). To evaluate process, a process baseline of interpersonal interaction behavior is established based on the three subsystems defined relationship skills. Dysfunction is viewed as a deviation from these principles of productive interactive process. In analyzing content, three marks of productive dyadic interaction are used: 61 1) Contextual Congruence: Productive relationship dyad interaction will have a well defined pattern of behaviors that is congruent to the systemic level impacted by the behaviors. Restated, any behavior sequence will be contextually congruent. 2) Continuity of Meaning: A productive relationship dyad will have a well defined pattern of meaning that is congruent with the consensus of the prior transactions in the communication sequence. 3) Consensual validation: Productive relationship dyad interaction will have a well defined pattern of a unity of meaning thrust into the relationship by the sender to which the respondent replies*with.some level of acceptance, creating a consensus (Beerthuis, 1991, p. 10). In addition, DeVoogd identifies the following three levels of dysfunction: 1.) Mild Dysfunction - members of the dyad lack adequate models. There is no discernable cognitive nor affective disorder. 2.) Moderate Dysfunction - dysfunction that demonstrates rigid, cyclical behavior with inadequate ego strength. 3.) Severe Dysfunction - dysfunction excluding dyadic interaction. 62 We Trimodal has two sets of coding symbols: model symbols and process symbols. Through the use of this coding system, dyadic interaction can be represented symbolically (both micro- and.macro-analytically). This symbolic representation is then. evaluated. based. on. the Trimodal delineation. of productive interaction skills. The Trimodal Coding System uses the following symbols: W I- Identity Affirmation N - Needs Contracting P - Problem Solving W -- new meaning thrust or consensus for new meaning thrust I, N, P simple clarification statement, no validation ? question / identity diffusion (Identity Affirmation) <--> displaced focus thrust on self or other (Needs Contracting) 1 blocked transaction (Problem Solving) : transaction terminated 63 P-l-P talking around a subject without consensus lNlNl consensus impasse We H husband W wife ceding Symbols will be used as follows: Speaker Symbol + Modality Symbol + Process Symbol H or W + I, N, or P + /, <--> or 1 Examples: H I --, W N <-—>, H P 1 Conclusion None of the present marital interaction coding systems were designed to produce data that provide immediate helpful information to the therapist during therapy. Other coding systems have been designed primarily for research. The purpose of this research is to train marriage and family therapy interns in the concepts of Trimodal and its coding system and to evaluate the replicability of the coding system. CHAPTER III: METHODOLOGY The focus of this project was to evaluate the replicability of the Trimodal Coding System based on agreement of the participants with the experts and to establish interaction reliability of the Trimodal categories. The overall question of this study was: Is the Trimodal Meta-model a stable enough model that trained subjects can recognize its components with a high degree of accuracy (consistency)? Three additional questions were: 1.) Can subjects be trained to distinguish between the three modalities of Trimodal? 2.) Can subjects be trained to distinguish between productive and nonproductive dialogue using the categories of Trimodal? 3.) Can subjects be trained to distinguish between nonproductive use of the three modalities using the categories of Trimodal? HYPOTHESES For the purposes of this research the following hypotheses were used: 64 65 H : Research subjects' codings of interaction modalities will a1 show agreement with experts' codings. : Research subjects' codings of interaction modalities will not show agreement with the experts' codings. 3.2: Research subjects' codings of productivity and nonproductivity will show agreement with experts' codings. H02: Research subjects' codings of interaction modalities will not show agreement with the experts' codings. H's: Research subjects' codings of nonproductive use of the three modalities will show agreement with experts' codings. H03: Research subjects' coding of nonproductive use of the three modalities will not show agreement with experts' codings. This study used an exploratory, post-test only design to investigate the replicability of the Trimodal Coding System. The research identified subjects; provided an intervention to them in the form of a training session; and immediately administering an instrument to assess their ability to replicate the coding of the experts. The unit of analysis was the individual interns involved in this research project assessment of Trimodal Meta-model. EQDnlfltiQn_flnQ_§§le§ The research sample was obtained in two phases. The research sample for phase one was selected from the population 66 of marriage and family therapy interns in the Ph.D. program at Michigan State University. Twenty-four (24) interns were mailed letters inviting them to participate in this research project and a response card was enclosed (see Appendix B). Follow-up phone calls were made to twenty-two (22) interns whose response cards were not received within ten days. A total of six (6) interns volunteered for this research project and were given a choice between two workshop dates on Saturdays one week apart. Confirmation cards were sent to volunteers (see Appendix B). A third workshop was planned and the remaining eighteen interns were mailed announcement letters, plus a letter from the Marriage and Family Therapy Program Director, Dolores Hunt, which were followed by phone contact. Three interns volunteered and received two reminder mailings prior to the workshop and a follow-up call the evening prior to the workshop. (see Appendix F). Phase two of obtaining the research sample involved MFT interns at the University of Illinois--Springfield. Approximately twenty-five interns received notice of the workshop in their department newsletter (see Appendix G). In addition, notices were placed on department bulletin boards (see Appendix H), and distributed to other faculty in the department. Handwritten notes to students and faculty were also sent out by William Abler, Assistant Professor in Human Development Counseling who coordinated the workshop offering 67 and registration. Eleven volunteers were obtained. Their registration for the workshop was confirmed by mail (see Appendix M) and follow-up calls were made to all participants four days prior to the workshop. Procedures The following four procedural tasks were necessary: (1) the documentation of the Trimodal Meta-model: (2) the documentation of participants in the Trimodal Coding System; (3) the instruction of participants in the Trimodal Meta-model and the coding system, and (4) the design of an instrument to assess mastery of the Trimodal Coding System. Documentation of Trimodal began in 1988 during the researcher's internship under the supervision of DeVOogd. In addition, the researcher participated in formal and informal training in Trimodal. Supervision in Trimodal was also provided by Barbara Beerthuis, who was a protege of DeVoogd. DeVoogd and Beerthuis also provided the researcher with personal writings and insights from their clinical experience. Documentation of the Trimodal Coding System was accopmlished.through.ongoing dialogue between the researcher, DeVoogd and Beerthuis. Symbols previously used by DeVOogd (see Chapter II) were refined for simplicity. The coding symbols chosen for the purpose of this research were: 68 E I l' I l !' 5 1 J I = Identity Affirmation N 8 Needs Contracting P = Problem Solving WWW / = Identity Diffusion <> = Displaced Focus 1 = Blocking Formulation of a single training session to convey Trimodal was accomplished through direct collaboration with DeVOogdl DeVoogd provided access to his personal writings on the model, direct supervision and consultation. Beerthuis provided access to her own manuscripts, direct supervision and consultation. Both Beerthuis and DeVoogd are approved clinical members and approved supervisors of the American Association for Marriage and Family Therapy. The researcher designed the materials for the workshop, which were based on the documentation. of model (see Literature Review) and inclusion of examples from DeVoogd's personal writings (see Appendices, p. 128-132). 69 NW The location of Phase One workshops was in the Human Ecology Building of Michigan State University. The location of the Phase Two workshop was held at the Counseling and Therapy Training Center on the University of Illinois campus in Springfield, Illinois. All workshops were held in large rooms with tables and chairs which could be arranged as needed. An overhead projector was used throughout all the workshops and.participants received handouts of all materials used on the overhead. A half-hour lunch break was given midway through the workshop. Both locations were convenient to parking. The buildings were quiet and free from student traffic, as all were held on Saturday. The format of the workshop was educative and interactive. Participants asked questions, explored ideas, clarified concepts as the researcher presented materials on Trimodal and its coding system. The presentation of the workshop was in the following sequence: 1.) Historical background of Trimodal 2.) Assumptions of Trimodal (Appendix A) 3.) Hypotheses of Trimodal (Appendix A) 4.) Modalities of Trimodal (Appendix A) 5.) Skills of each modality (Appendix A) 6.) Relational position of dyad per modality (Appendix A) 7O 7.) Coding symbols (Appendix A) 8.) Markers and example of productive transactions (Appendix A) 9.) Administration of Part I of assessment instrument (Appendix B) 10.) Markers and examples of nonproductive transactions (Appendix A) 11.) Administration of Part II of the assessment instrument (Appendix C) Instrumentation Development of the assessment instrument utilized.marital therapy session transcripts of Beuschel and DeVoogd. Dialogue from. these sessions was analyzed for representation of productive and nonproductive interactions. To achieve equal representation of all areas of the model to be assessed, five non-marital interactions were used. With the exception of one statement, all segments chosen contained at least one speaker switch. Representative interactions for the assessment instrument were chosen by consensus of Beuschel, DeVoogd and Beerthuis. The productive modality coding symbols (I, N, P) were assigned.to dialogue that demonstrated.the speakers' use of a modality skill as defined in Figure 4, "The Trimodal Modalities and Skills". The nonproductive modality coding symbols (/, <>, 1) were assigned to dialogue that reflected either speakers' inability to demonstrate productive interaction in a modality. 71 The instrument consisted of twenty-four items divided into two parts. Part I was comprised of twelve dialogue segments representing productive interaction modes. Subjects were asked to identify which modality was represented by circling one symbol: I, N, or P. Part II was comprised of twelve items representing both productive and nonproductive interactions. Subjects made two distinctions: first, to distinguish between the interaction as productive or nonproductive; and second, to code the nonproductive interactions according to the modality: /, <>, or 1. Figures 6 a 7 show the assignment of dialogue segments from the instrument to the model. Subjects recorded their responses on a two page answer sheet by selecting the appropriate coding symbol. Since this was the first use of the instrument, its reliability and validity were not known; however, the development process provided. a basis for assuming face validity. 72 "I came out not being the victim or martyr, and that's really important to me." "You seem to have a hard time figuring out how to "I have a hard time differentiating my responsibilities and those of my children. "Tell me about yourself." "I'm a person who gets frazzled thinking about getting through today or tomorrow." "John is a hard working man." "I haveno compassion for him working hard." Won ”I feel overwhelmed when I think of all those people coming for the pig roast. "We can work it out together in figuring how the load could be lightened on both of us. "I need to care for us, me and my baby." "I'm proud to care for you both." "What's bothering you?" "All I'm asking is that we buy disability insurance for you from your business." "I feel worried when you're out riding your motorcycle. After your last accident, I don't want you in the hospital again." "It would be helpful to me if we could deal with those feelings together." 3. H — "What happened?" W - 7. T - be a good mother." C - 9. T - C - 10. T - C - 2. W - H - ‘8e W - H - 11o H - W .- .12. W - H - Figure 6: Identification of Statement Modality Part I of Instrument 73 Figure 6 (cont'd). P I 1. W - "In order to help Tom, we've got to figure out who these kids are." (wksp. 1) H - "That's one thing that I admit is a bad habit of mine, forgetting people's names." 1. W - "In order to help Tom, we've got to know the names of Tom's friends." (wksp. 2&3) H - "That's one thing that I admit is a bad habit of mine, forgetting people's names. - ”What can I do to help?" - "You can roast the pig." - "What happened when the water valve broke?" Did you call the city water for help?" - "I called the plumbers for help and they were here quickly." - "Alright, here's the problem. We have two sons in Engineering school. They want to join you in your business." 74 "There you go again, trying to dominate me." "I'm not trying to dominate you." "You're not?" "No." "Because when you tell me I shouldn't feel a certain way it sounds like you're trying to control my life." "I'm not. I'm just trying to be helpful." "Sometimes when I get busy and forget family details and chores I'm scared." "I know family is top priority for you and I feel secure with you." "Thanks. I thought about you in the middle of a business meeting. I hoped that you could handle it if it gave you trouble." "I was angry when it happened. But I know how pressured you've been remodeling the house, and this emergency business trip. You're forgiven, but never forgotten." , because Suzie ran away." "I had just pulled down the drapes to wash them and had them soaking in the basement sink when she ran away. I was so worried about getting them washed and hung up again." "With all the plane crashes recently, I'm really nervous about flying." "Don't be such a jerk!" "I'm sorry to hear your mother died." "Ya, went fishing yesterday and caught a beautiful bass. 7: Identification of Statement Modality Part II of Instrument 75 Figure 7 (cont'd). ; HQEEBQDEQIIYE (CODt'd)- l 14. W - "Again you are very late!" H - "Got caught in traffic. Sorry. What's for dinner?" - W - "I have had it up to my eyeballs today with l stress and disappointments. This has been a ! terrible day. Don't you think you could have the consideration to call me if you know you're going to be late? We've been over this a hundred times." 17. H - "You shouldn’t blame yourself eery time Bobby misbehaves." W - "Don't (you) tell me how to feel. (You) stop trying to dominate me!" 19. H - "I hate that you're the type of person who never ‘ thinks to call and tell me you'll be late coming home. You always leave me hanging. You care more about your fiends than you do about our marriage." Blocking 16. H - "I just balanced the checkbook, and we have to be more careful." i W - "Money's your problem. Don't bother me with it!" 21. W - "Jenny's wet the bed again. Let’s call her doctor." H - "You've got a washing machine, take care of it!" .23. H - "I thought about you in the middle of a business meeting. I worried that you may have trouble with the water valve if it went out." "I could go to my mother's." - "Sometimes I get so busy and forget family details and chores I'm scared. Family is what it's all about." W - "I don't worry. You make lots of money." DIS I 76 W The evaluation of participants' responses on the assessment tool provided nominal data to be evaluated for interrater reliability. Nominal data as defined by Zeger (1991) is generated by raters who label categories without any order relation among the categories. "The degree of egreemem; between two raters who rate a number of objects on a certain characteristic can be expressed by means of an association co- efficient" (Zeger, 1991). When nominal data are analyzed, the class of Euclidean Co- efficient (EC) is utilized. Two representations of data are available for use: proportion.of agreement among judges (not corrected for chance) and proportion of agreement among judges corrected for chance using Cohen's kappa co-efficient. Fleiss (1971) supports the use of Cohen's kappa with data where more than two raters are used and the raters are independent of each other, as is the case in this research. The formulas used in the statistical analysis are: 1.) Proportion of agreement among subjects and between subjects and experts not corrected for chance: % = P0/1 2.) Cohen's kappa.- proportion agreement among subjects and between subjects and experts correct for chance: kappa (PO - PC)/(1 - PC) 77 PO refers to proportion of interrater agreement PC refers to proportion of interrater agreement expected by chance alone The use of kappa provides an estimate whether or not the level of chance-corrected agreement between subjects is significantly greater than zero. Guidelines have been established to compensate for varying sample sizes and.their effect on the significance factoru The guidelines define the levels of kappa which may be regarded as clinically or substantively important. Kappa values <.40 indicate "POOR" levels of interrater reliability, values between .40 and .59 indicate "FAIR" levels of reliability, c.) values between .60 and .74 indicate "GOOD" levels of reliability, and values => .75 reflect "EXCELLENT" levels of reliability (Cicchetti, 1984). Results of the data analyst will be presented in the form of tables and matrices. Limitations and Assumptions Ii '! l' The data collected had several limitations. The sample size of twenty was small and not randomly selected. No measurement of prior knowledge of Trimodal was given. No pretest was given to assess intuition, common sense or prior 78 knowledge. No pilot workshop was conducted and therefore one modification of workshop material was necessitated between the first and second workshop. No differentiation was made between participants based on their hours or years of clinical experience. W It was assumed that all workshop material was of equal difficulty and the essence of the model could be communicated in five hours. It was also assumed that subjects in all workshops were independent and that there was no interaction between subjects in workshops one, two and three between the workshop periods. In addition, it was assumed that all subjects started at an equal level of knowledge of Trimodal. CHAPTER IV: RESULTS This research project was designed to evaluate the replicability of the Trimodal Coding System. Through the use of an assessment instrument, the scores of trained subjects were compared to the experts. This chapter will include sociodemographic data, research findings and a discussion of the findings. Data related to the findings and a discussion of the findings will be reported by hypothesis. Three null hypotheses ‘were tested and each. will be evaluated on the related findings: Hm: Research subjects' codings of productive interaction modalities will not show agreement with the experts' codings. H02: Research subjects' codings of productive interaction and nonproductive modalities will not show agreement with experts' coding. H03: Research subjects' codings of nonproductive modalities will not show agreement with experts' codings. SocioeconomiLDoto Nine interns from the Michigan State University marriage and family' therapy’ program, and. eleven. interns from.the 79 80 University of Illinois at Springfield's Human Development Counseling Program participated in this research project. All participants were over twenty-five years old; four males and sixteen females (one Mexican American; one African American; and eighteen Caucasians). None of the participants held a state license in a mental health profession. The average hours of clinical experience were 577 with a range of 2- 2,000+ hours. Findings Three hypotheses were formulated to explore the replicability of the coding system by trained subjects. Each hypotheses will be presented with one agreement matrix not corrected for chance and one corrected for chance using Cohen's kappa. MW Part I of the assessment instrument consisted of twelve dialogue segments representing four each of three modalities: Identify Affirmation, Needs Contracting, and Problem Solving (see Appendix J). Table 1 shows agreement between subjects and subjects' agreement with experts not corrected for chance. The average agreement of all subjects with subjects was .62. The average agreement of all subjects with experts was .73. Table 2 shows agreement between subjects and subjects’ 81 agreement with experts corrected for chance. The average agreement of all subjects with subjects corrected for chance was .43. The average agreement of all subjects with experts corrected for chance was .60. This part of the assessment instrument was guided by Hm: research, subjects' codings of productive interaction modalities will not show agreement with the experts' coding. The results of the pooled agreements of subjects with experts using the transformation to correct for chance yields a kappa of .60 and rejection of Hm: A kappa greater than .60 or less than or equal to .74 reflects "good" levels of reliability (see Table 7). 82 one... 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The average agreement of all subjects with experts was .89. Table 4 shows agreement between subjects and subject's agreement with experts corrected for chance. The average agreement of all subjects with subjects corrected for chance was .65. The average agreement of all subjects with experts corrected for chance was .78. This part of the assessment instrument was guided by H02. The results of the pooled agreements of subjects with experts using the transformation to correct for chance yields a kappa of .78 and rejection of Bar A kappa greater than or equal to .75 reflects "excellent" levels of reliability (see Table 7). 85 com... N33332:. Eco—.9. l >< an. on. me. on. an. cu. :. no. no. on. :. an. an. no. on. an. as. _a. no. on. m e._ o.- ~a. 3. 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N3-. N3- .. 3N. 33. NN. 33. 33. 3N. 3N. 33. 33. 3. 33.. 33i- 3N. .3. 33. 33. N3. .3. .N .l 33. NN. 33. 3N. 33. 3.. 3.. 3 3N. 33. 3N. 33. 33. 33. N 33. 3N. 3.. NN. 3N. 3 .3. 3N. 33. 33. N 3N. -3Ni. 3N- 3 33. .3. N 3.. N N 3NN..3qNN3.N.iN.N.l:3.33NNNNNN. 330.com 3:32.335 >3. m...“ 00 o>2o3ootdcoz oco 33.269.3— mcfitmmom .0320 ..o. coauotou 3396 one Nuuibom :oozzom use 333.“ coozaom cozflottouufic. Non—ocuolou raou=osm l .. Eon... 87 Part IIb of the assessment instrument consisted of the identification of the nine nonproductive dialogue segments by their modality coding symbol: / (Identity Diffusion), <--> (Displaced Focus), and 1 (Blocked Transaction). Table 5 shows agreement between subjects and subjects' agreement with experts not corrected for chance. The average agreement of subjects with all subjects was .42. The average agreement of all subjects with experts was .54. Table 6 shows agreement between subjects and subjects' agreement with experts corrected for chance. The average agreement of all subjects with subjects for chance was .14. The average agreement of all subjects with experts correct for chance was .32. This part of the assessment was guided by H03. The results of the pooled agreements of subjects with experts using the transformation to correct for chance yields a kappa of .32 and rejection of Hg. A.kappa less than .40 indicates a "poor" level of reliability (see Table 7). £38 coo... 3033.33.33... flue—Not x 33 N3. N3. 33. .N. 33. NN. N3. N3. 3N. NN. 33. NN. 33. 33. NN. 33. 33. N3. 33. .m 33. NN. 3N. 33. NN. 3N. N3. N3. 3N. NN. N3. NN. 33. 3N. 3N. NN. 33. NN. 33. NN. 3 33. N3. 3N. 3N-l N3. 33. 3N. 3N.. NN.. NN. NNi- NN.l N3. N3. 3N. .3N. i3 .NNl. NN. 3N N3. NN. N3. 3N. NN. N3. 33. NN. NN. N3. N3. 3N. NN. N3. N3. 33. 3N. NN. N. 3N. N3. NN. 3N. N3. 3N. NN. 3N. N3. NN. NN. NN. N3. N3. 3N. 3N. NN. 3.- NN. 3N. 3N. 3N. 3N. NN. NN. N3. 33. N3. N3. 33. 33. 33. N3. NN. N. N.. 3N. .NN. NN. NN. N.. NN. N.. NN. 33. NN. NN. 3N. NN. NN. 3. NN. 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NN. .3.- N..- 3N N.. .3.- N.. NN. .3.- N.. .N .3.- .3.- N.. N.. NN. .3.- N.. N.. NN. NN. N..- N. NN. N.. .3.- NN. N.. NN. .3.- NN. N.. .3.- .3.- N..- N.. N.. NN. NN. NN. -l3«. .3.- NN. NN. NN. NN. .3.- .3.- N.. NN. N.. N.. .N. .N. .N.. N..l .3.- N. 33.- NN. .3.- N... N..L 33.- N..- 33.- .3.- NN.- N..- N..- NN. N..- .3.- 3. .3.- N.. NN. N.. N.. N.. N..- NN. N.. N.. N.. .3... N.. .3.- N. .3.- N.. .3.- .3.- N..- N..- .3.- 33.- N.. NN. NN. .3.- N.. 3. NN. NN. N.. N.. .3.i N.. N.. NN. .3.- .3.- N.. NN. N. . .3.- N.. NN. NN. NN. NN. .NN. N.. NN. N.. N.. N. .3.- NN. 33.- N.. N..- N.. .N. 33.- N.. NN. .. .3.- N..- N..- NN. N.. N..,N..- NN. Nui. 3. .3.- NN. N.. NN. NN. NN. NN. NN. N NN. NN. NN. N.. .N. N.. .- 3 N..- NN. N.. NN. NN. N.. N . NN. NN. .3.- .3.- N.. 3 NN. .N. NN. .3. N NN- NN. -N3-. 3 NN.. N... N NN.. N . .lluw 3. line. .N. lluN N. 3. N. N. N. leN. N .lul- .lN- 3 N 3 N N . 3.393 m: Sue—ban 3:22.33: xn 93:60 3:322 02.259552 @5253. 3:25 ..o. peace-Zoo a 33333.. cesium use 3.33.5 racism cozsotooNuE. Nco_u=3o-ou coop_.u:w l 3 oBah 90 Table 7: Pooled agreements of subjects with experts using kappa Data from Reliability Reliability Matrix by by Proportion Category HYPO 1 _ .666 .666 HYPO 2 ,888-.5 = .3§8§ .78 Excellent PROD VS. .5 .5 NON | ' HYPO 3 l 4 -. 3 = . 11 .32 poor * /<-> 1 .666 .666 Source: Cichhette, Heaveno et a1. 1987, p. 672 CHAPTER V: DISCUSSION 1] E' J: E H . I E .1 I] The field of Marriage and Family Therapy continues to grow as evidenced by the 20,000 members in the American Association of Marriage and.Eamily Therapy and the forty to sixty thousand practicing Marriage and Family Therapists. Clinicians from.a variety of disciplines such as psychology, social work, education and medicine are found in this field. Many of these disciplines have professional organizations which have formed their own subgroups of marital and family therapists. The continuing growth of the field of Marriage and Family Therapy reflects society's concern about the survival of the family units as the impinging forces of world place more demands on the family and its resources. Churches, schools, governments and businesses are turning to those knowledgeable about the dynamics of family life to provide them with information that will enable them to respond to the needs of families. Research in this field provides a significant contribution to the base of knowledge about families which can be shared across disciplines to stabilize the family unit, the building block of our society. 91 92 The clinical skills of a marital and family therapist evolve over time and are anchored in a program of academic study of the family. Clinical training is closely supervised. Both are guided by accreditation standards of university programs or state licensing boards. The AAMFT membership standards are often used as a guideline for licensing or accreditation. Knowledge and experience combine to produce the marital and family therapist. In order to be effective in the practice of marital and family therapy, the therapist must be able to develop a set of skills that allow him/her to accurately read the dynamics of interpersonal interaction and derive meaning from them. Based on the derived meaning, the therapist then intervenes to bring about change. All of this taking place while interacting with the family in a sometimes emotionally charged situation. The therapist's ability to successfully perceive, conceptualize and intervene simultaneously or sequentially is key to his/her professional effectiveness. It is therefore imperative for the therapist to be able to move from theory to practice. W This study contributes to the field of Marriage and Family Therapy in several ways, First, it provides an authorized documentation of DeVoogd's Trimodal and Coding System. Due to the death of DeVoogd in 1995, further interest in Trimodal 93 will be dependent on the research of and dialogue with DeVoogd's proteges. Second, through this research, the Trimodal Coding system has proven to be a viable training tool for marriage and family therapy interns. After five hours of training, both novice and experienced interns were able to effectively use this coding system. Third, the intern trained in Trimodal and its coding system can use this model for assessment, intervention and evaluation in the practice of marital and family therapy. Finally, this study provides groundwork for further research based on Trimodal. The field of Marriage and Family Therapy continues to grow to meet the needs of individuals and families as they grow and change. Trimodal offers training programs, clinicians and researchers in the field of Marriage and Family Therapy a model to meet these needs. Limitations ' ocurement The procedure for obtaining the sample for workshops one and two had several weaknesses. The response card design enabled only an acceptance response rather than both an acceptance or rejection response. It did not prove effective, as ten days after mailing only two responses were received with handwritten rejection messages. After three rounds of 94 phone calls to the twenty-two remaining potential participants, six participants were identified. Schedule conflicts with the stated workshop date resulted in a second workshop date being arranged. Nonparticipants rejected participation due to a variety of reasons: time constraints, schedule conflicts, length of workshop, family priorities, and not wanting to complete an assessment instrument. Due to poor planning, the mailing' occurred between Thanksgiving and Christmas holidays. Since the semester had ended, several interns had already left for the holidays and the researcher never reached four of the potential participants. Reminder notices and personal phone calls solidified workshop participation and commitment on the part of volunteers. Prior to use of these two tools for workshops three and four, one workshop had been canceled on site due to lack of volunteer participation on the day of the workshop. ill] HI! 'JIII'E'H The researcher followed the same format for all four workshops (see Chapter III, page 68). After input from participants in workshop one, the researcher modified question number one on the assessment instrument by changing a phrase in an effort to reduce ambiguity (see Appendix K). The ability of participants to reach agreement with the experts on this item.before and after modifications was poor. 95 Question number one was missed fifteen out of twenty times, possibly this is indicative of an ambiguous dialogue segment in need of replacement. For workshops two, three and four, the researcher deleted using written examples of nonproductive dialogue, as it was the researcher's intuition that the examples created confusion and better understanding could.be accomplished through verbal explanation rather than written example. While taking the assessment instrument, participants were permitted to utilize all handout materials. The participants demonstrated their understanding of the use of the symbols rather than their ability to memorize or retain workshop information. The assessment instrument included husband-wife, therapist-client, and client only dialogue segments which may have weakened its credibility as an assesssment instrument for coding marital dialogue. Two segments were single statements not representative of interaction. Participants commented that isolated statements were most difficult to identify, as they felt their context was unclear. Participants reported that they "read into" statements too much rather than taking them at face value, which created confusion in the coding process. 96 Part I of the instrument required participants to distinguish.between three productive modalities. It was felt by the researcher that the scores for this section would be higher. Question number one was missed fifteen out of twenty times; therefore, having a large effect on the scores, and bringing into question its validity. Questions two through twelve totaled had forty-seven missed out of two hundred and forty (table 8). A trial run of this instrument would have allowed the researcher to replace ambiguous or poor questions. Table 8 - Frequency of Incorrect Answers by Question Part I - Productive Modality Distinction Question Number Correct Response Frequency Missed 1 P 15 1 2 N 8 3 I 4 4 P 7 E 5 P 3 i e p 7 F 7 I 4 ‘ 8 N 3 . 9 I 0 ~ 10 I 2 1 11 N 4 g 12 N 5 Part II of the assessment instrument required participants to make two distinctions, first choosing between productive 97 and nonproducitve interactions and second choosing between three nonproductive modalities. 0n the first distinction, twenty-seven of two hundred and forty possible distinctions were missed. Question number fifteen was missed seven times, and number nineteen was missed five times. Two questions were missed once and three questions were missed zero times. Productive dialogue segments were missed twelve out of sixty times (20%) and nonproductive segments were missed fifteen out of one hundred and eighty times (8%). A. trial run of the instrument would have permitted replacement of frequently missed items and a balance in level of difficulty of productive and nonproductive dialogue statements. The second distinction of three nonproductive modalities yielded the highest errors, one hundred.out.of two hundred.and forty (42%) missed distinctions. 0f the three modality choices, the Identity Affirmation modality was missed with the greatest frequency, thirty eight out of sixty times (63%) (table 9). It was anticipated by the researcher that the nonproductive modality distinction would be the most difficult for the participants to learn and this confirmed this assumption. This part of the instrument was completed during the last half hour of the workshop, during which time participants could have been experiencing fatigue. The increasing level of the workshop material's difficulty' must also be considered. Question 15a had the highest frequency of being missed in this section, which overall was the strongest performance section 98 on the assessment tool. Table 9 - Frequency of Incorrect Answers by Question Part IIa - Productive - Nonproductive Distinction I Question Number Correct Response Frequency Missed I ! 13a N 0 14a 15a 16a 17a 18a 19a 20a 21a 22b 23c LEE—“-..... Z'UZZZ'UZZ'UZ ObHHOU‘bONQw It was felt by the researcher that Part I would be the easiest distinction to make and the scores would be the highest of the three distinctions on the assessment instrument. However, the average agreement of subjects with experts not corrected for chance was .73 (Table 1) and corrected for chance was .64 (Table 2). The best performance by subjects was on Part IIa, the distinction of productive vs. nonproductive dialogue where the average agreement of subjects with experts not corrected for chance was .89 and corrected (Table 3) and .78 corrected for chance. The most difficult 99 distinction was on Part IIb, the nonproductive modality selection which was .54 not corrected for chance and .32 corrected for chance. A reorganization of the training program and the assessment tool by level of difficulty would be appropriate based on these findings. A hierarchy of training based on level of performance could also be considered. A review of the performance by subjects on specific questions raises questions as the weaknesses of certain dialogue segments to clearly represent a given modality. As indicated on Table 8, question number one was missed fifteen out of twenty times despite its change after workshop one. Questions number 13b, 19b, 23b and 24b 'were :missed frequently (Table 10). These frequencies call into question the ability of the question to clearly represent the researcher's intent as an example. 100 Table 10 - Frequency of Incorrect Answers by Question Part IIb - Nonproductive Modality Distinction Question Number Correct Response Frequency Missed 13b / 17 14b ---> 10 15b * 6 16b 1 7 17b ---> 5 18b * 4 19b --—> 9 Ir 20b / 10 4 21b 1 3 22b * 1 23b 1 16 24b =”___fl/ 11 _ Correct answer is: * = No response Nuances of the Data Training Eggggs Instrument Design Weaknesses in the training and the instrument design need to be considered when reviewing the research data (table 7). A restructuring of the training sequence to reflect increasing levels of difficulty might enhance performance on the assessment instrument. A modification from a five hour training session to two or more shorter sessions could reduce participant fatigue. A performance level criteria could be 101 established for each training session. A restructuring of the training sequence would necessitate a possible restructuring of the assessment instrument and items that were frequently missed (tables 8 & 9) could be replaced. - t-' -;_ '11:-31“ :3 i- a ‘-°_ 1;... _. The subjects' average hours of clinical experience were 577, with a range of 2-200+ hours. Subjects' scores corrected for chance ranged from 1.0 to 0.1. An informal investigation of subjects' scores related to clinical hours seems to show that the more clinical experience the subject had, the lower the subjects' score on the assessment instrument. One subject, who had been trained on assessment tools used in the university clinic, stated that during the first two hours of the workshop she had to try to "unlearn" her prior clinical training and may interfere with their ability to learn and utilize a new therapy model. Strength_2f_tha_neta Using table 7, the average of the pooled agreements with experts corrected for chance using Cohen's kappa is .57. 'This indicates a "fair" level of reliability for ‘the entire assessment instrument. This was accomplished with a minimal number of training hours (5). The strength of model is 102 evidenced in the strength of these findings. Strengths of Trimodal The positive responses of the research subjects have been encouraging. At each workshop, participants expressed appreciation for the training received and interest in applying Trimodal to their future clinical work, recognizing that much more extensive training and supervision would be necessary to use it exclusively. The ethnically unbiased nature of Trimodal was identified in one workshop by a participant. The participant was working with other marriage and family interns to identify a ethnically mutual assessment tool for use in an on-campus therapy clinic. She expressed interest in Trimodal also due its simplicity, and. ability' to be used for’ assessment, intervention and ongoing evaluation. In an ad hoc fashion, positive response on the training session at the University of Illinois was received. Dr. William Abler communicated the positive reception of Trimodal by his interns to Dr. Donald Melcer, research committee member, and Michigan State University professor emeritus. 103 qo-a ° 1 ' at". 1C 100_O.C! 0 s_fta :99 am _ us=_:9 For at least twenty years, Al DeVoogd had been training marital and family therapist at the Marriage and Family Center of Grand Rapids. Throughout this time he continued to refine Trimodal as he supervised others and maintained a full time private practice. His powerful clinical skills and supervision of clinicians did not translate to an interest nor ability' to create a :research. design. to demonstrate ‘the effectiveness of Trimodal. Documentation of Trimodal remained within his personal records. Protege's have referenced Trimodal in graduate papers. To date no published document exists on Trimodal; yet many thriving private practitioners learned their skills using Trimodal. As described in Chapter II, DeVoogd considered Trimodal a meta-model. As a meta-model it provides an organizational structure which enables the therapist to evaluate the level of productive interaction taking place during a therapy session. The degree of productivity is measured by the presence or absence of the interactive skills as detailed in the three modalities of Identity Affirmation, Needs Contracting and Problem Solving. Having assessed the level of productive interaction, the therapist uses interventions to create positive change in the interaction. Trimodal provides the 104 therapist with a tool to assess, intervene and evaluate progress in marital and family therapy. The use of Trimodal does not necessitate an allegiance to a particular theoretical model. Therapists are free to utilize interventions based on their theoretical preferences (Chapter II) to achieve change in the interaction skills as defined by the model. When working with interns or clinicians in training, DeVoogd respected the individual's theoretical preferences and assumed the individual was knowledgeable in human development and individual and family life cycles. DeVoogd developed a coding system for Trimodal which added to the efficiency of its use. With or without pencil and paper, the trained therapist can code the flow of interaction and assess its productivity. There is no need for elaborate or costly recording equipment. There are no documents to score or code for hours after the therapy session. The therapist using Trimodal is unencumbered. Full attention can be given to the process of the therapy session. The Trimodal Coding System offers a cost and time efficient tool for the practice of marital and family therapy. Trimodal is a practical model for training Marriage and Family Therapy interns. In a concise manner it offers the intern a model for productive interaction that can be used for assessment, intervention, and evaluation in marital and family therapy. Described as a metamodel by DeVoogd, it is able to provide an operational structure for existing theories in the 105 field of marriage and family therapy. It is cost effective both in its application and training time, as evidenced by this study. Trimodal is a sound training model, unique in its simplicity of form and expansiveness of application. Vi il° There is a lack of theoretically compatible training protocols that teach interns a clear and precise way to become effective therapists. The Handbook of Family Therapy (Gurman and Kniskern, 1981) offers a systematize and comprehensive review of "major current clinical concepts in family therapy" (Gurman & Kniskern, 1981, pvii). Specific guidelines were followed for each review and these included a section entitled "Training of Marital-Family Therapists". Of the seventeen approaches reviewed, only Structural Family Therapy had a clearly defined training program for marital and family therapists. This gap between theory and practice leaves many therapist piecing together theory and clinical tools to form a "patchwork quilt” approach to clinical practice. The use of Trimodal as a training model and clinical framework will fill this void. Based on this research project, it has been demonstrated to be a reliable training method. It requires few training hours and is effective with marital and family therapy interns who have varying hours of clinical experience. CHAPTER VI: SUMMARY AND IMPLICATIONS The field of Marriage and Family Therapy is relatively young compared to other mental health fields such as psychiatry and social work. Historically, families' needs for mental health services have been reflective of societal changes. Wars, depression, recessions, scientific and medical advances, increased mobility and information overload have exerted pressures on the family unit and increased the demand for marriage and family therapy. At the same time, families are experiencing limited financial resources for mental health and government and private sources are focusing on cost containment through managed health care. Those compounding factors demand that Marriage and Family Therapists be efficient and effective. Coding systems have been developed as a therapeutic aid to assess or evaluate clients. Most coding systems have their origins in a research setting. They are time and cost intensive and therefore not practical for daily clinical use. They requrie recording equipment so that coding can be done after the therapeutic session. Coding systems to date have offered a snapshot look at the client's present level of functioning, but have not been able to bridge into treatment 106 107 planning, interventions and ongoing assessment of client progress. In response to this need, this research focused on the Trimodal Coding System developed by DeVoogd. This coding system provides a shorthand for codifying the process of dyadic interaction for the purpose of assessment, intervention, or progress evaluation. The replicability of this coding system was evaluated to explore the potential of this code as a training device for marriage and family therapists. This study was an exploratory, post-test only design to investigate the replicability of the Trimodal Coding System by marriage and family therapy interns. Data collection was done by means of the completion of an assessment instrument at the end of a five-hour training workshop. The participants' responses on the assessment instrument were compared with the experts and corrected for chance. The overall research question of this study was: Is Trimodal a stable enough model that trained subjects can recognize its components with a high degree of accuracy (consistency)? The research questions included: (a) can subjects be trained to distinguish between the three modalities of Trimodal; (b) can subjects be trained to distinguish between productive and nonproductive dialogue using the categories of Trimodal; and (c) can subjects be trained to distinguish between three nonproductive use of the 108 three modalities using the categories of Trimodal? The results of this study indicate that the Trimodal Coding System can be replicated at good levels on Part I and excellent levels on Part II of the assessment instrument which is an affirmation response to questions a and b. A poor level of replicability was achieved on Part IIb which results in a negative response to question c. With the majority of the responses positive to the coding system's replicability, the overall question could, be answered in the affirmative. Overall, the researcher felt that the trainees were able to accomplish a fair level of expertise in the use of Trimodal. These findings are encouraging in terms of the usefulness of the coding system for training clinicians. Use of the coding system could provide a shorthand and common language for therapists. The good level of replicaiblity achieved on distinctions of the three productive modalities give credence to its usefulness, not only in training but in application to transcripts of dialogue segments. Excellent levels of replicability of the coding on productive/nonproductive dialogue segments is indicative that interns can learn to make these distinctions. Poor levels of replicability on the modality' distinctions of nonproductive dialogue segments indicate that participants could be taught the coding system; however, not with as high a degree of replicability. Fatigue, increased levels of difficulty, training time, test weariness all could have effected the performance of the participants' 109 ability to learn and utilize the coding. These findings can be generalized to the population of internship level mental health professionals. The researcher believes that under different circumstances a higher level of replicability could be achieved. Reorganization of the training material would allow the trainer to increase the level of difficulty as reflect in replicability levels from this research; i.e, first Part IIa, (excellent), second Part Ia (good) and third Part IIb (poor). In addition, the trainees could be expected to achieve a certain level of performance on that section of the assessment tool before moving on in training. The varied performance by individual participants, on the assessment tool, indicates that three distinctions in the training were independent of each other. A participant's high/low score on one part of the assessment tool did not predict participant's high/low scores on the two other parts. Therefore, the training could be divided into three distinct sections of increasing difficulty and could be offered at different times in order to decrease the length of a training session. The use of computer technology and video tapes could enhance the delivery of training and assessment. Video taped segments of marital therapy could be used in the training and assessment process. A computer program could be designed to provide a learning medium that was self correcting as the 110 trainee's knowledge was assesed after a training session. Replicability might also improve if trainees were more homogeneous in entry level skills, course work in Marriage and Family Therapy and hours of clinical experience. The sample involved in this research had a wide variety of clinical hours and course work. Implications for Further Research Through this research, some answers have been found regarding the replicability of the Trimodal Coding System.and additional questions have come to light as the focus shifts from this specific research project. 1. Can marriage and family therapy interns achieve higher levels of replicability than licensed therapists? 2. Can trained participants produce excellent levels of replicability on longer dialogue segments? 3. Can trained participants produce high levels of replicability on live dyadic interaction? 4. Can the Trimodal coding system be applied microanalytically to an entire therapy session? 5. Can the Trimodal coding system accommodate cultural diversity? 6. Can the Trimodal coding system be applied to non marital of types of dyadic interaction; i.e., parent-child, teacher- student. 111 This research provides a training model and coding system for further research in dyadic communication. Future research could apply the Trimodal Coding system to a wide variety of dyads seen in marriage and family therapy, such as, parent- child, child-child, parent-parent, grandparent-parent, or grandparent and child. Additional research could also be conducted to evaluate improved methodology in a training protocol for marital and family therapy interns based on the Trimodal . APPENDICES Appendix C Introductory Letter to Perspective Participants Werkshop III 112 November, 1994 Dear Marriage and Family Therapy Interns, I am a doctoral candidate in the Department of Family and Child Ecology with a specialization in Marital and Family Therapy at Michigan State University. I am contracting all MFT interns who have accumulated 100+ hours of clinical work to request their voluntary participation in my dissertation research. The time commitment involved will be approximately five hours to attend a workshop and complete an assessment tool. This will take place from 10:00 to 3:30 on Saturday, January 7, 1995 at the Human Ecology building, room.f9. There will be a 1/2 hour break for lunch. The focus of my study is a meta-model for marriage and family therapy. I am developing a training program for this model which results in the use of a coding system that is shorthand for the therapist. My research analyzes the replicability of this coding system by trained interns. As a volunteer in this study, you will receive approximately five hours of training in Trimodal Meta-Model and Coding System. Upon completion of the training, you will be asked to complete a brief assessment tool in which you will code interactions using the Trimodal Meta-Model Coding System and your responses will remain anonymous. Enclosed is a brief Response Form. You will be indicating your voluntary agreement to participate in this study by completing and returning this form.to me. Your participation in this workshop will be kept confidential. No names will be attached to the collected data. You will receive a response from me confirming your request to participate in this workshop. Thank you for your time and consideration! Sincerely, Janice R. Beuschel, M.A., L.M.F.T. Dr. Robert Boger, Ph.D. (616) 842-6904 (h) Family & Child Ecology (616) 846-5880 (w) Appendix D Participant Response and Confirmation Cards WOrkshop III 113 Name: Address: Phone: (H) ('1) Best Time to Call: (H) (W) I would like to participate in your research project and can attend the workshop on Saturday, January 7th from 10:00 - 3:30. Signed: PLEASE RETURN THIS FORM ASAP. THANK IOU! QQNEIBNATIQN Ih14II1l9§£l_!§£§_flfldgl_flnlkfihfln This card is to confirm your reservation for this workshop on Saturday, January 7, 1995 from 10:00 - 3:30 at the Human Ecology Bldg., Room #9. There will be a half-hour break for lunch. If you have any further questions, please contact me evenings at 616-842-6904. Janice Beuschel, M.A. Licensed Marriage and Family Therapist Appendix E Reminder Letter WOrkshop III 116 A Place is Reserved for You Where: M.S.U. Campus, Human Ecology Bldg., Rm. #9 When: Nov. 18,1995 10:00 '- 3:00 What: Participation in Janice Beuschel’s Research Project Why: Good Question” To increase my samplesizesoleanGraduate—Yippee! 7144944414“th WM . Ma W (616) SW afin 7mm Appendix F University of Illinois, Springfield Department Newsletter - WOrkshop IV 117 UPCOMING WORKSHOP Bill Abler would like to invite all interested students to participate in an upcoming MFT workshop to be held Saturday, April 27, 1996 from 10:00 a.m. - 3:30 p.m. in the Counseling and Therapy Training Center (PAC 494) There is no fee for this event. See below for further details. Dear HDC, CFC, and PSY Students: I am a doctoral candidate in the Department of Family & Child Ecology with a specialization in Marital Family Therapy at Michigan State University. I am contacting all interested HDC, CFC, and PSY graduate students to request their voluntary participation in my dissertation research. Participants must meet the following criteria: 1) interested in marriage and family therapy training, certification and/or licensure; and 2) completion of a minimum of 100 hours clinical experience-practicum and/or internship (HDC, CFC, and PS! graduates are also invited to participate). The time commitment involved will be approximately five hours to attend a workshop and complete an assessment tool. This will take place from 10:00 a.m. - 3:30 p.m. on Saturday, April 27 at the Counseling Therapy and Training Center, PAC 494. There will be a 1/2 hour break for lunch. The focus of my study is a meta-model for marriage and family therapy. I am developing a training program for this model which results in the use of a coding system by trained interns. As a volunteer in this study, you will receive approximately five hours of training in Trimodal Meta-Model and Coding System. Upon completion of the training, you will be asked to complete a brief assessment tool in which you will code interactions using the Trimodal Meta-Model Coding System and your responses will remain anonymous. Below is a brief response form. You will be indicating your voluntary agreement to participate in this study by completing and returning this form to Debbie in the HDC office. Your participation in this workshop will be kept confidential. No names will be attached to the collected data. Thank you very much for your time and consideration! Janice Beuschel, MA, LMFT 118 Upcoming Workshop (cont.) Workshop IV 1 Participation Response Name Address Phone (H) (W) I would like to participate in your research project and can attend this workshop on Saturday, April 27 from 10:00 - 3:30 in the Counseling and Therapy Training Center (PAC 494) Signed: Please return to Debbie in BRR 332 ASAP. Thank you. Appendix G University of Illinois, Springfield Bulletin - Workshop IV 119 Whe CACREP COUNSELOR Snidentscturentlyeruolledinthe l-IDCProgrammaytakeadvantage of priority registration on Monday, April 22. Wis will beavailable before thattime inthe HDC Program Office. All the WPIs thatwere intheProgram officehavealreadybeensent overtoregisnationandshouldbeonfilewhen you truism Students in the school counseling program who need HDC $31 Developmental School Counseling can take it this fall. That course will be offered under the supervision of James Lanier. Students who plan to take that course should sign up with Regina as soon as possible. SIGMA SIGMA UPSILON EVENTS The next induction ceremony of Sigma Sigma Upsilon, the local chapter of Chi Sigma Iota has been scheduled for April 25 at 7 p.m. in PAC Conference Room 6. CHAPTERMEETING On May 6, 1996 Sigma Sigma Upsilon is holding a chapter meeting for all interested SSU members. Sue Passo, an HDC graduate, will be the feamred speaker. The meeting begins at 7:00 p.m. and will be held in PAC Conference Room NB. We look forward to seeing you there. Q xenon coxns AVAILABLE Anystudentwho isamemberof Sigma Sigma Upsilon and will be participatingincommencementthis yearmayptlehasenhonorcm'dtowearto gnduationt'romxallchnm'. CordscostSlO. ContactKellyorJameslmim'forfiumer I E II DEAN’S SEARCH Schoolot'liealthand HtunanServicesiscmrmnlyconductinga searchforanherimdean. DeanMulcahywill stepdawnfiomthflpositionAugmt 15. Atthe presenttimathecommimeeisaccepting M.A. mom GUIDELINES JudyShipphasjustcompleteda thoroughrevisionoftheMA. ProjectGuidelines. Thesewillbe availablenolaterthanApril 15. Theyare availabletosmdentsinlack’sresemchcotne fieeofchargeuponcompledonofthecom'se. ‘l'heBookstm'ewillmaintaincopiest'orsalefor thoseindividualswhowishtoreplacetheir MW- Oneofthebasisofadvisingtlnqpem'sinthe newguidelinesisthatsmdentsprepmingm adviseronthflopiebet‘oresubmitthgthe nova-lbw JACK GENSKOW’S RETIREMENT OnAugnatlSJaekGenskowwillrem'e fromthel-lDCProgI-amathe'serving 18 yeal'sonthefacnlty. Smdentswhoplan mbehareinthel’allandamlaek’s l @m 119a advisees should check with him to express their preference for a new adviser. Jack will help them makeoutthenecessary formstotnnsfer to the new adviser in August. / / e swarm IN WHO'S WHO f Congratulations to the following HDC students who were meatly included in the 1996 edition ofWho '3 Who Among Students in American Universities and Colleges. Rita Buddemeyer. Betty Bushey, Merrie Colgrove, and Randy Dionne. These students were chosen based on their academic achievement, service to community, leadership in emacurricular activities, and potential for continued success. UPCOMING WORKSHOP Bill Abler would like to invite all interested students to participate in an upcoming MFT workshop to be held Saturday, April 27, 1996 from 10:00 a.m. - 3:30 p.m. in the Counseling and Therapy Training Center (PAC 494). Thereisnofeeforthisevent. Seebelowfor further details. Dear HDC, CFC, & PSY Students: lamadoctoralcandidateintheDeparnnentof Family & Child Ecology with a specialintion in Marital and Family Therapy at Michigan State University. I am contacting all interested HDC, CPC. and PSY graduate students to request their voluntary participation in my dissertation research. Participants must meet the following criteria: 1) ' interested in marriage and family therapy training. certification and/or licensme; and 2) completion ofa minimum of 100 hours clinical. experience - practicum and/or intm'nship (HDC, Cl-‘C,andPSY graduatesarealsoinvitedto participate). The time commitment involved will be approximately five hours to attend a workshop and complete an assessment tool. This will take place from 10:00 a.m. - 3:30 p.m. on Sanu'day, April 27attheCounseiingTherapy and Training Center, PAC 494. There will be a Khourbreakforlunch. ‘I'hefocusofmysmdyisameta-modelfor marriageandfamilythmapy. lamdevelopinga trainingprogramfordiismodelwhichresultsin theuseofacodingsysmmthatisshorthandfor thetherapist. Myresesrchanalymthe replicabilityofthiscodingsysternbynained inuns. Asavolrmteerinthisstudy,youwill receiveappoximateiyfivehorusofn-ainingin TrimodalMem-ModelandCodingSystem. Uponcompledmofthenamingyouwillbe askedtocompleteahriefassessmenttoolin whiehyouwillcodeinmractionsusingthe TrimodalMeta-ModelCodingSystemandyour responseswiilremainanonymous. Belowisabriefruponseform. Youwillbe indicatingyourvolrmtaryagreementto participassinthissmdybycompletingand renuningthisformtoDebbieinthei-DCoifice. Yoruparticipationinthisworkshopwillbekept confidential. Nos-sawillbeattaehedtothe collecteddata. Thankyonvmymuchforyoru timeandconsideratimrl JaniceMMLMl-T Wharton” Name Address Phone: (H) (W) lwouldliketopmtmipa'm much pojectandcanatmndthiswmkshoponSmday. April276om10-3z30hmaCormseltngand TherapyhamingCemara’AC494). Siped qumr-mmm. The-Ryan. Appendix H Reminder Letter WOrkshop IV 120 * Reminder * Reminder * Reminder * Reminder * Reminder * A place is reserved for you . . . Where: Counseling and Therapy Training Center (PAC 494) University of Illinois at Springfield. When: Saturday, April 27, 1995 10:00 a.m. - 3:30 p.m. What: Trimodal Meta-Model and Coding System Workshop Who: Janice R. Beuschel, MA, LMFT Ph.D. Candidate Michigan State University NAN! THANKS IN ADVANCE FOR YOUR PARTICIPATION IN THIS TRAINING AND N! RESEARCH PROJECT! Questions? (616) 842—6904 after 7:00 p.m. Appendix I Training Materials Workshops I - IV 121 BASIC ASSUMPTIONS OF THE TRIMODAL META-MODEL The Trimodal Meta-Model is based on five assumptions as defined by Dr. Albert DeVoogd: 1) All transactions are analyzed as dyad interactions. 2) Three primary modes of interaction comprise the dyad systems available for analysis. These three modes are: a. Dyad interactions that define and affirm individual identity. The dyad interaction outcome is the formation and affirmation of individual identity. b. Dyad interactions meeting personal emotional needs of both of the dyad components. The interaction outcome is personal and emotional needs are met within the dyad. c. Dyad interaction resulting in productive work. The interaction outcome is productive work as wealth production. 33) The three interaction modalities can be defined as skill sets of: a. Identity Formation and Affirmation 122 b. Needs Contracting c. Problem Solving 4) The life development process is movement toward fulfilling the three interaction outcomes through relationship skill mastery. 5) Personality can be defined as a set of coping strategies based on personal traits and characteristics directed toward the fulfillment of three interaction modalities. 123 HIPOTHESES OF THE TRIMODAL METAPMDDEL The following hypotheses are delineated by Dr. Albert DeVoogd: 1) The primary relationship dyad interaction can be defined and analyzed from the perspective of a secondary dyad. (Therapy) 2) The productive dyad will demonstrate a well defined set of skills in interaction modality usage at the relationship interface. 3) Productive relationship dyads will demonstrate a flexibility in interaction modality selection for patterns of interaction with the dyad. (Dysfunction) 4) Productive relationship dyad will have a well defined pattern of consensual validation in communication transactions. (Consensual Validation) 5) Productive relationship dyad will have a well defined pattern of meaning thrusts that are congruent with the consensus of prior transactions in the communication sequence. (Continuity of Meaning) 6) Productive relationship dyad interactions will have a well defined pattern of contextual congruence in relationship transactions. (Contextual Congruence) 7) The persons in a productive relationship will demonstrate, as under their control, a rhythmic movement 124 across a continuum from a point characterized as individual uniqueness demonstrated by autonomous actions to a point characterized as oneness, union and fusion demonstrated by interlocking behaviors. (Relationship Evaluation) 125 IDENTITY AFFIRMATION NEEDS CONTRACTING PROBLEM SOLVING The Trimodal Meta-Modal Modalities 126 F—m ---— — — IDENIIIX_AEEIBMAIIQN Self Awareness Awareness of Other Self Disclosure Acceptance of Other Delineation of Acceptance of a Needs System Needs System Delineation of Commitment to Specific Needs Meet Need P LE 0 1. Definition and ownership of problem by sender. Commitment to joint ownership by receiver. 2. Identification of possible options. 3. Selection of a course of action. 4. Implementation of course of action. 5. Evaluation. The Trimodal Meta-Modal Modalities and Skills 127 Identity Affirmation Needs Contraction Problem Solving Relational Position of Dyad in Each Modality 128 [ PRODUCTIVE NONPRODUCTIVE Symbol: Symbol: 129 TRIMODAL CODING SYSTEM Model Symbols: I - Identity Affirmation N - Needs Contracting P - Problem Solving Process Symbols: -- New meaning thrust or consensus for new meaning thrust / Identity diffusion (Identity Affirmation) <--> Displaced focus thrust on self or other (Needs Contracting) Blocked transaction (Problem Solving) Speaker Symbols: H Husband T Therapist W Wife C Client Coding: Symbols will be used as follows: Speaker Symbol + Modality Symbol + Process Symbol H or W + I, N, or P +--, /, <--> or Examples: H I --, W N <-->, H P 130 PRODUCTIVE INTERACTION Dr. DeVoogd developed the following set of three hypotheses to define healthy, productive interaction based on the Trimodal Meta-model: 1) The productive dyad will demonstrate a well defined set of skills in interaction modality usage at the relationship interface. 2) The persons in a productive relationship will demonstrate, as under their control, a rhythmic movement across a continuum from a point characterized as individual uniqueness (demonstrated by autonomous actions), to a point characterized as oneness, union, and fusion (demonstrated by interlocking behaviors). 3) The productive relationship will demonstrate a flexibility in interaction modality selection for patterns of interaction within the dyad (Beerthuis, 1991, p. 10). 131 NONPRODUCTIVE INTERACTION Dysfunction is viewed as a deviation from these principles of productive interactive process. In analyzing content, three markers of productive dyadic interaction are used: 1) Contextual Congruence: Productive relationship dyad interaction will have a well defined pattern of behaviors that is congruent to the systemic level impacted by the behaviors. Restated, any behavior sequence will be contextually congruent. 2) Continuity of Meaning: A productive relationship dyad will have a well defined pattern of meaning that is congruent with the consensus of the prior transactions in the communication sequence. 3) Consensual Validation: Productive relationship dyad interaction will have a well defined pattern of a unity of meaning thrust into the relationship by the sender to which the respondent replies with some level of acceptance, creating a consensus (Beerthuis, 1991, p. 10). 132 THREE LEVELS OF NONPRODUCTIVE INTERACTION In addition, Dr. DeVoogd identifies the following three levels of dysfunction: 1) Mild Dysfunction - Members of the dyad lack adequate models. There is no discernable cognitive nor effective disorder. 2) Moderate Dysfunction - Dysfunction that demonstrates rigid, cyclical behavior with inadequate ego strength. 3) Severe Dysfunction - Dysfunction excluding dyadic interaction. 133 Interaction Skills In the Three Relationship Modes Skill Set 1 Interaction Mode 1 The individual identity definition and affirmation skill set is a transaction consisting of: on the part of the sender, the skill of some level of personal self awareness and self disclosure: on the part of the respondent, with the reciprocal skill of the sender self disclosure and acceptance of the sender as a significant other. Example An identity Affirmation transaction. Hu is visiting Wi in the hospital after a C section delivery of their first child. Wi. 1A (Overwhelmed) I'm a mother! Hu. 2a You're so beautiful. The Wi. is sharing an awareness of herself. The Hu. is responding with acceptance of her as a significant other in his life. e e t' o t w ' ' w' the relationship, Trans- action charac- teristic This Hu. Wi. transaction is congruent within our cultural understand and practices of the birth of a child. This acceptance within the broad social context is labeled W. The identity affirmation modality is the basic transaction that affirms and enhances personal, individual self worth in the self differentiation process. In the text cited above this took place when the Wi. could say to her husband, "I'm a 134 mother!" with the confidence that "I am known by him as I really am and he accepts me." The human value inherent in this modality is the worth of the individual. Skill 2 Personal Needs Contracting skill set is a Interaction transaction consisting of: Mode 2 on the part of the sender, skill in the delineation of the senders need system and, the definition of specific need to a significant other; on the part of the respondent, skill in the awareness of the need system of the sender and some level commitment to the sender at the point of defined need. Illustra- (The dialogue continued) tion: Wi. 1B I need you to care for us, me and our baby. Hu. 2b I'm proud to care for you both. Trans- Two characteristics of this skill are: action Charac- >in the flu. Wi. communication there is a teristic cumulative theme development within an orderly flow of ideas, and >the behaviors in this communications transaction are congruent within the intent of both persons. This characteristic of the congruent development of an idea or a theme within the relationship dyad will be labeled CONTINUITY OF MEANING. 135 The transaction results in emotional bonding through gratification of personal, emotional needs within the dyad. In this text, the Wi. could say to her husband, "I need you to care for me and our baby." She could say to herself, "He knows how I need him and I am safe with him.” The human value in this transaction is the inherent demand for integrity in contracting. Skill #3 The Problem Solving skill set as the social function of productive work is a transaction consisting of skills: on the part of the sender of a definition of a problem and ownership of it; and on the part of the respondent of an acceptance of the problem as defined and a commitment to joint ownership of the problem and some form of a co-operative problem solving effort. Illus- tration (The dialogue continued) Hu. I'll work hard at it. In fact, I'm working on a family budget. Do you want to help when you are able? Wi. Sounds exciting. Let's do it together. WW elicit—echLngi. Hu. Get well quick. I miss you at home. Closure, Trans- action Charac- teristic The characteristic of this skill is that, in the Hu., Wi. communication there are mutually understood communication signals of consensus and an orderly introduction of new content 136 (ideas) resulting in an ongoing development of ideas. This characteristic is labeled CONSENSUAL VALIDATION. In the text cited, this is indicated in the Hu. sending the message: Hu. 1C "I'll work hard at it. (Consensus on Wi. statement of needing care) In fact, I'm working on a family budget. (New information thrust into the dyad) Do you want to help when you are able?" (Further new input eliciting consensus from Wi.) and the Wi responding... Wi. 2c "Sounds exciting. (Consensus) Let's do it together." (Further (elaboration of meaning) They are joined in their commitment to their work of living together and of raising their child in the world. The interaction modality results in work commitment, given within the dyad, as a social contribution to the broader community. In return for joint expression through work, the community bestows a sense of being accepted. 137 Dysfungtigg_13giggtg;§ are process symbols indicating three interaction of dysfunctional behavior: .....1./ .....2.<--> This indicates a dysfunctional transaction in the identity mode. This will be a dysfunctional statement of identity. This will usually be a detached, asocial-avoidant behavior pattern that is not congruent within the broader social context. This indicates a dysfunctional transaction in the needs contracting modality. This will be a dysfunctional statement of needs. The displaced focus behavior patterns as dependent counter- dependent. This results in discontinuity of meaning in the transaction sequence. <-Displaced focus on other ->Displaced focus on self This indicates a dysfunctional transaction in the problem solving modality. This will be a dysfunctional approach to problem solving indicating blocking patterns. These blocking patterns of behavior are identified as dominant, controlling behaviors blocking effective problem solving. Blocked transaction Appendix J Assessment Instrument workshop I 138 TRIMODAL METAPMDDEL CODING SISTEM ASSESSMENT Section I #1 - #12 W = wife H = husband T = therapist C = client 1. W - "In order to help Tom, we've got to figure out who these kids are." H - "That's one thing that I admit is a bad habit of mine, forgetting people's names." 2. W - "I feel overwhelmed when I think of all those people coming for the pig roast." H - "We can work it out together in figuring how the load could be lightened on both of us." 3. H - "What happened?" W - "I came out not being the victim or martyr, and that's really important to me." 4. H - "What can I do to help?" W - "You can roast the pig." 5. H - "What happened when the water valve broke? Did you call the city water for help?" W - "I called the plumbers for help and they were here quickly." 139 6. W - "Alright, here’s the problem. We have two sons in engineering school. They want to join you in your business." 7. T - "You seem to have a hard time figuring out how to be a good mother." C - "I have a hard time differentiating my responsibilities and those of my children." 8. W - "I need you to care for us, me and my bab ." H - "I'm proud to care for you both." 9. T - “Tell me about yourself." C - "I'm a person who gets frazzled thinking about getting through today or tomorrow." 10. T - "John is a hard working man." C - "I have no compassion for him working hard." 11. H - "What's bothering you?" W - ”All I'm asking is that we buy disability insurance for you from your business." 12. W - "I feel worried when you're out riding your motorcycle. After your last accident, I don't want you in the hospital again." H - "It would be helpful to me if we could deal with those feelings together." 140 Section II #13 - #22 13. T - "Mary, you called and asked for this appointment because Suzie ran away." C - "I had just pulled down the drapes to wash them and had them soaking in the basement sink when she ran away. I was so worried about getting them washed and hung up again." 14. W - "Again you are very late!" H - "Got caught in traffic. Sorry. What’s for dinner?" W - "I have had it up to my eyeballs today with stress and disappointments. This has been a terrible day. Don't you think you could have the consideration to call me if you know you're going to be late? We've been over this a hundred times." 15. H - "I'm not trying to dominate you." W - "You're not?" H - "No." W - "Because when you tell me I shouldn't feel a certain way it sounds like you're trying to control my life." H - ”I'm not. I'm just trying to be helpful." 16. H - "I just balanced the checkbook and we have to be more careful." W - "Money's your problem. Don't bother me with it!" 141 17. H - "You shouldn't blame yourself every time Bobby misbehaves. W - "Don't (you) tell me how to feel. (You) stop trying to dominate me!" 18. H - "Sometimes when I get so busy and forget family details and chores, I'm scared." W - "I know family is top priority for you and I feel secure with you." 19. H - "I hare that you're the type of person who never thinks to call and tell me you'll be late coming home. You always leave me hanging. You care more about your friends than you do about our marriage." 20. W - "With all the plane crashes recently, I'm really nervous about flying." 21. W - "Jenny's wet the bed again. Let's call her doctor." H - "You've got a washing machine, take care of it!" 22. H - "Thanks, I though about you in the middle of a business meeting. I hoped that you could handle it if it gave you trouble." W - "I was angry when it happened. But I know how pressured you've been remodeling the house and this emergency business trip. You're forgiven but never forgotten." 23. H - ”I thought about you in the middle of a business meeting. I worried that you may have trouble with the water valve if it went out." W - "I could go to my mother's" H - ”Sometimes I get so busy and forget family details 142 and chores I'm scared. Family is what it's all about." W - "I don't worry. You make lots of money." 24. T - "I'm sorry to hear your mother died." C - "Ya, went fishing yesterday and caught a beautiful bass." Appendix H Assessment Instrument - WOrkshops II - IV 143 TRIMODAL METAPMODEL CODING SYSTEM ASSESSMENT Section I #1 - #12 W = wife H = husband T = therapist C = client 1. W - "In order to help Tom, we’ve got to figure out who these kids are." H - "That's one thing that I admit is a bad habit of mine, forgetting people's names." 2. W - "I feel overwhelmed when I think of all those people coming for the pig roast." H - "We can work it out together in figuring how the load could be lightened on both of us." 3. H - "What happened?" W - "I came out not being the victim or martyr, and that's really important to me." 4. H - "What can I do to help?" W - "You can roast the pig." 5. H - "What happened when the water valve broke? Did you call the city water for help?" W - "I called the plumbers for help and they were here quickly." 144 6. W - "Alright, here's the problem. We have two sons in engineering school. They want to join you in your business." 7. T - "You seem to have a hard time figuring out how to be a good mother." '1 . C - "I have a hard time differentiating my responsibilities and those of my children." -‘-.‘l __fi'F—n- ‘_¢ 8. W - "I need you to care for us, me and my baby." H - ”I'm proud to care for you both." 9. T - "Tell me about yourself." C - "I'm a person who gets frazzled thinking about getting through today or tomorrow." 10. T - "John is a hard working man." C - "I have no compassion for him working hard." 11. H - "What's bothering you?" W - "All I'm asking is that we buy disability insurance for you from your business." 12. W - "I feel worried when you're out riding your motorcycle. After your last accident, I don't want you in the hospital again." H - "It would be helpful to me if we could deal with those feelings together." 145 Section II #13 - #24 13. T - "Mary, you called and asked for this appointment because Suzie ran away." C - "I had just pulled down the drapes to wash them and had them soaking in the basement sink when she ran away. I was so worried about getting them washed and hung up again." 14. W - ”Again you are very late!" H - "Got caught in traffic. Sorry. What's for dinner?" W - "I have had it up to my eyeballs today with stress and disappointments. This has been a terrible day. Don't you think you could have the consideration to call me if you know you're going to be late? We've been over this a hundred times." 15. H - "I'm not trying to dominate you." W - "You're not?" H - "No." W - "Because when you tell me I shouldn't feel a certain way it sounds like you're trying to control my life." H - "I'm not. I'm just trying to be helpful." 16. H - "I just balanced the checkbook and we have to be more careful." W - "Money’s your problem. Don't bother me with it!" 146 17. H - "You shouldn't blame yourself every time Bobby misbehaves. W - "Don't (you) tell me how to feel. (You) stop trying to dominate me!" 18. H - "Sometimes when I get so busy and forget family details and chores, I'm scared." W - "I know family is top priority for you and I feel secure with you." 19. H - "I hare that you're the type of person who never thinks to call and tell me you'll be late coming home. You always leave me hanging. You care more about your friends than you do about our marriage." 20. W - "With all the plane crashes recently, I'm really nervous about flying." 21. W - "Jenny's wet the bed again. Let's call her doctor." H - "You've got a washing machine, take care of it!" 22. H - ”Thanks, I though about you in the middle of a business meeting. I hoped that you could handle it if it gave you trouble." W - "I was angry when it happened. But I know how pressured you've been remodeling the house and this emergency business trip. You're forgiven but never forgotten." 23. H - "I thought about you in the middle of a business meeting. I worried that you may have trouble with the water valve if it went out." W - "I could go to my mother’s." 147 H - "Sometimes I get so busy and forget family details and chores, I'm scared. Family is what it's all about." W - "I don't worry. You make lots of money." 24. T - "I'm sorry to hear your mother died." C - "Ya, went fishing yesterday and caught a beautiful bass. Appendix L Response Form - Workshops I - IV 148 RESPONSE FORM - TRIMODAL METAPMDDEL CODING SYSTEM MI: Circle the coding symbol most representative of the modality (skills) being demonstrated in each interaction sequence. I = Identity Affirmation N = Needs Contracting P = Problem Solving 1.)I NP 2.)I NP 4.): NP 6.)I NP 7.): NP 149 8.)I NP 9.)I NP 10.) I N P 11.) I N P 12.) I N P W Identify each interaction sequence as either PRODUCTIVE OR NONPRODUCTIVE by circling the word in "part a". If the sequence is identified as NONPRODUCTIVE, complete "part b" by indicating the modality of the sequence by circling its coding symbol. Identity diffusion \ ll <--> = Displaced focus 1 = Blocking 13.) 14.) 15.) 16.) 17.) 18.) 19.) 20.) PRODUCTIVE / <--> PRODUCTIVE / <--> PRODUCTIVE / <--> PRODUCTIVE / <--> PRODUCTIVE / <--> PRODUCTIVE / <--> PRODUCTIVE / <--> PRODUCTIVE / <--> 150 NONPRODUCTIVE 1 NONPRODUCTIVE l NONPRODUCTIVE l NONPRODUCTIVE l NONPRODUCTIVE l NONPRODUCTIVE l NONPRODUCTIVE l NONPRODUCTIVE 1 (complete (complete (complete (complete (complete (complete (complete (complete Nb") Nb") Nb") IIb") lib") IIb") lib") Mb") 151 21.) a. PRODUCTIVE NONPRODUCTIVE - (complete "b") b. / <--> 1 22.) a. PRODUCTIVE NONPRODUCTIVE - (complete "b") b. / <--> 1 23.) a. PRODUCTIVE NONPRODUCTIVE - (complete "b") b. / <--> 1 24.) a. PRODUCTIVE NONPRODUCTIVE - (complete "b") Hours of clinical experience / = <--> = 1 REFERENCES LIST OF REFERENCES Andreozzi, Lucille L. Why outcome research fails the family therapist- Integratinu_3eaearch_and_§linical_2ractice. Andrews, Mary P., Bubloz, Margaret M. & Paolucci, Beatrice. (1980, Spring\Summer). 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