The practice of systemic therapy, domain 1

A therapist asks, "Who in the family gets most upset when your son has trouble at school, and what does that person do?" In Tomm's classification, this is an example of which type of question?

1. Linear question
   A linear question asks for facts or causes about one person ('When did his trouble start?'); this one asks about others' reactions.
2. Strategic question
   Strategic questions are leading and corrective, nudging toward an answer the therapist prefers; this one is exploratory.
3. Circular question
   Asking who gets most upset and what that person does explores reactions and relationships around the problem, which Tomm calls a circular question.
4. Reflexive question
   Reflexive questions are hypothetical or future-oriented and invite new possibilities; this one maps the existing pattern.

The more a wife presses her husband to talk about his feelings, the more he withdraws, and the more he withdraws, the harder she presses. An MRI brief therapist would MOST likely:

1. Explore the husband's underlying attachment fears
   Exploring the husband's attachment fears is EFT; the MRI model works on observable attempted solutions, not inner experience.
2. Teach both partners active listening skills
   Teaching active listening is behavioral skills training; MRI changes the problem-maintaining sequence instead of adding skills.
3. Construct a genogram of pursuit patterns
   A genogram of pursuit patterns is Bowen multigenerational work; MRI stays with the present interaction.
4. Direct the wife to stop asking for a week
   In the MRI model her pressing is the attempted solution that keeps his withdrawal going, so the therapist directs her to do something different: stop asking.

As her 16-year-old walks in the door, a mother says sharply, "It's 11 o'clock." Both know she means more than the time. In Watzlawick's axioms, the part of her message that defines how she sees their relationship is the:

1. Digital content level
   Digital communication is the verbal, content-carrying mode; the relational message travels through tone and context (the analogic mode).
2. Report level
   The report level is the literal content, the time; it carries information but says nothing about the relationship.
3. Command level
   The command (relationship) level defines how the speaker sees the relationship: here, that she is in charge and he is late.
4. Punctuation of sequence
   Punctuation is how each person divides an ongoing sequence into causes and effects, not the relational level of a single message.

Whenever a wife raises money worries, her husband changes the subject to the children's activities. The therapist asks the couple to talk about finances for 10 minutes without mentioning the children. This intervention BEST illustrates:

1. Blocking the avoidance pattern
   Asking them to stay with finances and leave out the children shuts down the usual detour, so the couple must stay with the avoided topic: blocking the avoidance pattern.
2. Prescribing the symptom paradoxically
   Prescribing the symptom would tell them to keep changing the subject; the therapist forbids the detour instead.
3. Unbalancing toward the wife
   Unbalancing means affiliating with one partner to shift the balance of power; this rule applies to both partners equally.
4. Coaching a Bowen I-position
   A Bowen I-position is one person calmly stating their own stance; the therapist here sets a rule for the couple's interaction.

A couple competes in every argument: each insult is met by a harsher one, and each raised voice by a louder one. This interaction BEST illustrates:

1. Pseudomutuality
   Pseudomutuality (Wynne) is a facade of harmony that hides divergence, the opposite of open competition.
2. Complementary interaction
   Complementary interaction pairs opposite behaviors, such as dominant and submissive or pursuer and distancer, not matching ones.
3. A double bind
   A double bind is a contradictory message at two levels that the receiver cannot escape or comment on, not an escalating exchange.
4. Symmetrical escalation
   Each insult met by a harsher one and each raised voice by a louder one is mirroring between equals, which, unchecked, becomes symmetrical escalation.

In a first session with a recently immigrated Vietnamese American family, the mother answers every question directed to her 15-year-old son, who defers to her. The therapist's MOST appropriate initial response is to:

1. Explore the family's norms about who speaks for whom
   Before treating the pattern as dysfunction, the therapist joins and learns how this family's norms define respectful speaking roles; what looks like a diffuse boundary may be a normal hierarchy.
2. Meet with the son alone to hear his view
   Meeting the son alone in the first session bypasses the parents' authority before the therapist knows the family's norms.
3. Name the pattern as enmeshment to the family
   Calling the pattern enmeshment pathologizes a possibly normal cultural hierarchy before it has been understood.
4. Block the mother and ask the son to answer
   Blocking the mother is a structural move that, before joining and cultural assessment, risks shaming her and losing the family.

A 24-year-old's parents pay her rent, call her daily, and weigh in on every decision; she feels unable to act on her own. According to Carter and McGoldrick, the key emotional task of HER life-cycle stage is:

1. Accepting responsibility for self
   In Carter and McGoldrick's leaving-home stage, the single young adult's key emotional task is accepting emotional and financial responsibility for self.
2. Accepting multiple exits and entries
   Accepting multiple exits from and entries into the family is the parents' task in the launching stage, a common mix-up because both generations are in transition.
3. Committing to a new couple system
   Committing to a new couple system is the task of the joining-of-families stage (the new couple), not hers.
4. Increasing boundary flexibility for independence
   Increasing boundary flexibility for children's independence is the task of families with adolescents.

A therapist believes the family's view that their son is "lazy" was created through shared language and cultural expectations, and can be revised through new conversations. This view reflects:

1. Constructivism
   Constructivism locates the construction of reality in each individual's mind, not in shared language between people.
2. First-order cybernetics
   First-order cybernetics treats the therapist as an outside observer of a family's feedback loops, not as a co-author of meaning.
3. Social constructionism
   Meanings built between people through shared language and culture, open to revision in new conversations, is social constructionism, the basis of narrative and collaborative therapies.
4. General systems theory
   General systems theory describes wholes, feedback and homeostasis; it says nothing about meanings created in language.

A woman's mother insists she come home for the holidays, but she plans to spend them with her husband, Tom. Her Bowen therapist coaches her before the call. Which statement BEST represents an I-position?

1. "You always make me feel guilty about the holidays."
   'You always make me feel guilty' is a reactive, blaming you-statement, not a calm statement of self.
2. "We all think you're being unfair about this, Mom."
   'We all think' speaks for others and recruits a triangle instead of stating her own position.
3. "Whatever you want is fine; I don't really mind."
   'Whatever you want is fine' gives up her position to avoid conflict, which reflects fusion rather than differentiation.
4. "I've decided to spend this holiday with Tom."
   'I've decided to spend this holiday with Tom' calmly states her own decision without attacking or giving in, which is a Bowen I-position.

A wife says her husband's frequent lateness proves he "doesn't care about me." A cognitive-behavioral couple therapist would MOST likely focus on:

1. Her negative attribution about his lateness
   Cognitive-behavioral couple therapy (Baucom, Epstein) targets attributions, here the inference that lateness means he does not care.
2. The attachment fear under her anger
   The attachment fear beneath her anger is the focus of EFT, not cognitive-behavioral couple therapy.
3. The couple's problem-saturated story
   A problem-saturated story is narrative therapy language; the CBCT focus is the specific attribution.
4. Accepting his lateness as a stable trait
   Accepting a partner's stable traits is IBCT's acceptance work; CBCT first examines whether her inference holds.

A 12-year-old's refusal to leave the house dictates where his parents can go and what they can do, although in every other way he is treated as a dependent child. Which concept BEST describes this pattern?

1. Parentification
   Parentification means a child takes on adult caretaking duties; this boy controls his parents through a symptom without caring for them.
2. A family projection process
   The family projection process (Bowen) is parents passing their anxiety onto a child who becomes its focus; it does not describe a child who holds power over his parents through a symptom.
3. An incongruous hierarchy
   The boy is a dependent child yet his symptom controls his parents' movements; Haley calls this an incongruous hierarchy, and therapy puts the parents back on top.
4. A pseudomutual relationship
   Pseudomutuality (Wynne) is a facade of harmony that hides divergence; this family's problem is a child in charge, not a show of togetherness.

At intake, a mother describes her 10-year-old son's tantrums. The therapist asks, "When he starts yelling, what does his father do, and then what happens next?" This line of inquiry is BEST described as:

1. Exploring multigenerational patterns
   Multigenerational patterns are explored across generations, for example with a genogram; this question stays in the present household.
2. Tracking the interactional sequence
   Asking what the father does and what happens next maps how each response prompts the next: tracking the interactional sequence that maintains the tantrums.
3. Assessing the child's mental status
   A mental status exam assesses the child's appearance, mood, thought and cognition, not family sequences.
4. Conducting a functional behavioral analysis
   A functional behavioral analysis also asks about antecedents and consequences but keeps the child's behavior as the unit, not the family loop.

A mother often tells her 11-year-old son, "Don't tell your father, he'll just overreact," and lets him skip the curfew his father set. A structural therapist would MOST likely identify:

1. A detouring triad around the son
   In a detouring triad the parents unite around the child to avoid their own conflict; here one parent sides with the child against the other.
2. Rigid mother-son boundaries
   Rigid boundaries produce distance; this mother-son bond is overly close and secretive, the opposite.
3. Emotional cutoff from the father
   Emotional cutoff (Bowen) is managing fusion by distance; the father is undermined, not cut off.
4. A cross-generational coalition
   The mother allies with her son against his father, hiding things from him and overriding his curfew: a cross-generational coalition that weakens the parental subsystem.

A husband being treated with medication by his psychiatrist for major depressive disorder attends couple therapy with his wife, who has become his caretaker and is increasingly critical. The MOST appropriate systemic approach is to:

1. Leave the depression to his psychiatrist
   Leaving the depression entirely to the psychiatrist splits the problem; the couple's cycle and his symptoms affect each other.
2. Address how depression and the couple's cycle interact
   Depression and couple distress maintain each other, so the therapist works on the caretaker-criticism cycle around his depression while coordinating with the prescriber.
3. See the wife alone for caregiver burnout first
   Seeing the wife alone first moves away from the couple pattern that is maintaining both people's distress.
4. Postpone couple work until his depression remits
   Postponing couple work until remission leaves a maintaining factor untouched; couple-based treatment of depression has research support.

The team behind the mirror sends a message to a family: "By staying ill, Anna keeps her parents focused on her and so protects their marriage. Everyone in this family is making a sacrifice to keep it together." This intervention is BEST described as:

1. Prescribing the symptom
   No directive tells Anna or the family to keep the symptom, so this is not yet a symptom prescription.
2. Unbalancing
   Unbalancing is Minuchin's siding with one member to shift power; this message praises everyone equally.
3. Externalizing the problem
   Externalizing (narrative therapy) turns the problem into a separate entity; here the symptom is credited with a family purpose.
4. Positive connotation
   Giving the symptom and everyone's behavior a benign, family-protecting purpose is Milan positive connotation, which lowers blame and resistance.

A 17-year-old begins spending weekends with a new partner. Her parents tighten her curfew and her grandmother calls daily to complain until she returns to her old routine. The family's response BEST illustrates:

1. Negative feedback
   The family counters the change and restores her old routine, which is negative (deviation-reducing) feedback in the service of homeostasis.
2. Positive feedback
   Positive feedback amplifies a deviation; this family works to undo it. 'Positive' does not mean helpful.
3. Second-order change
   Second-order change alters the family's rules; here the old rules are reasserted.
4. Morphogenesis
   Morphogenesis is a system's ability to change its structure; this family resists change.

A family has an unspoken understanding that no one may openly disagree with the father, and a second one that no one may ever point out the first. The second understanding is BEST described as a:

1. Family myth
   A family myth is a shared belief that protects the family's picture of itself, such as "we never fight." It is not a ban on talking about a rule.
2. Family ritual
   A family ritual is a repeated, shared practice such as a holiday routine; the scenario describes an unspoken ban on naming a rule, not a practice.
3. Double bind
   A double bind is a pair of contradictory messages at different levels sent to one person who can neither comment on them nor leave. A metarule can help set one up, but the two are not the same.
4. Family metarule
   A metarule is a rule about the family's rules. This one forbids anyone to name the first rule, which keeps the rule about the father beyond discussion and change.