Family Therapy Sculpt

If you’re discussing relationships in therapy, it can be useful to use a family sculpt (originally developed by Kantor and Duhl, 1973)  to gain a better understanding of the client’s support system and family dynamics.

Sculpts involve arranging figures (people or objects) in a given space, to represent the relationships they have with one another. If you are working with the entire family, then you can ask one person to arrange the others in positions around the room. If you are working with an individual, you can ask them to select objects to represent each family member including themselves.

Objects can include toy animals, chess pieces, cuddly toys or just random objects. When someone selects an object, its helpful to have a conversation about why they chose that item. For example, they might choose a dog if they feel they are loyal or a goat if they feel they are stubborn.

Generally the person picks an item to represent themselves first and places it in the middle of the table. They then select an item for a family member, place it on the table in relation to them and talk about the relationship. They continue this until they have covered all the important people in their life.

Placing someone far away may show that they feel distant from that person. Placing someone in the middle of two other figures might show that they are a mediator. Placing two facing one another might show conflict. There have been occasions when clients have walked out of the room and placed a figure outside of the door, which says a lot about the relationship.

They might also choose an animal to represent their mental health problem (eg depression as a black dog) and place it on the table to show how it affects their relationships. It may be that all the figures are united against the mental health problem or it may be that the mental health difficulty is keeping them isolated from other family members.

When discussing their relationships, its helpful to use circular questioning to invite other narratives and perspecitves; for example, asking ‘what do you think your brother would say about your relationship if he was here?’ or  ‘Where would he put the figures?’

You can also ask them how to sculpt how their relationships used to be in the past or how they would like them to look. Try not to assume that everyone wants their family close together. Some people may be happy that a family member is no longer taking an active role in their life.

Steps for a family sculpt using toy animals:

1. Explain that you are going to create a representation of their family on the table using toy animals.
2. Get them to chose animals for themselves, family, friends and possibly also their mental health problem.
3. Ask about each one:
   What traits do they share with that animal?
   What are their strengths and weaknesses?
   What animals does it get on with?
   Is it a predator or prey?
   How does it defend itself?
4. Ask them to place themself in the middle of the table and the other animals around them, based on how close they feel to them.
5. Ask about how they’ve arranged the animals:
   Why have you chosen to put them there and not closer to you?
   Is your sister on the edge of the table because you feel distant from her?
   Is your mum between you and your dad because she mediates?
   Is your brother facing you because he’s listening or arguing?
6. Include circular questioning about other perspectives:
   What animal would your Mum have picked for you?
   If your Dad was here, where would he put his animal?
   Do you think your sister would also think she was a cat?
   How would your brother arrange these?
   How close do you think your mum feels to your sister?
7. Try asking about changes:
   How were your family arranged before the anxiety?
   How would you like things to be?
   What would happen if this family member wasn’t on the table?
8. It can be useful to end by writing a letter to a family member (which can be therapeutic, whether they give it to the person or not) or making a plan for what things they want to do differently to improve their relationships.

Examples:

Client was a hardworking horse, protected by her Giraffe mother who was always watching over head. Grumpy Rhino Step-Dad doesn’t really deal with the kids much but keeps away the dangerous Tiger Biological Dad. Friend is a loyal dog, always nearby. Two other friends at school who are an elephant and horse.

Client (little vulnerable chick) is separated by her undisclosed sexuality (white cat) from her mum (chicken). No barriers between her and her friends as they are aware of her sexuality.

Client (baby giraffe) very close to her mum (adult giraffe facing her) but mum’s new partner (big strong elephant) keeps pushing client out of the way. Stubborn friend (goat) is always by her side. Younger brother (cow) is oblivious to the situation.

Some more examples:

Types of Mental Health professionals

I’m a Clinical Psychologist and one of the most common questions I get asked is about how my role differs from other mental health professionals. So, I’ve put together this guide to hopefully give you an overview of our roles:

Health Care Assistants (HCAs): HCAs assist other professionals by helping feed, clean and monitor patients. Anyone with relevant experience can become a healthcare worker.

Support Workers: Support Workers are unqualified staff who provide emotional or practical support for people who are experiencing difficulties. Sometimes they can provide low level therapeutic interventions like graded exposure, if supervised by a qualified member of staff.

Occupational Therapists (OT): OTs are professionals who have compelted a 3-4 year Undergraduate degree or 2 year Post graduate/Masters degree in Occupational Therapy. They offer practical support to people whose health prevents them doing the activities that matter to them. They may set up hand rails for people with physical disabilities or help people with mental health problems to restart hobbies and interests. They aim to help you improve your life through meaningful activity.

Mental Health Nurses: Nurses have generally completed a 3 year Nursing degree and work in hospitals and the community to support people with a range of mental health issues. They can support with medication, physical care and therapeutic interventions. They must be registered with the Nursing and Midwifery Council (NMC).

Social Workers: Social Workers use talking therapy, support and advocacy to help people deal with social factors in their life, including housing, relationships and employment. To become a Social Worker, you can complete a BSc Social Work degree or, if you have a relevant undergraduate degree, you can complete a 2 year post-graduate master’s degree in Social Work.

Clinical Associates in Psychology (CAPs): CAPs have completed an undergraduate degree in Psychology and then an 18 month full-time apprenticeship. They can work in the specific area of mental health that they have trained in (eg Adult community mental health) with supervision from a qualified psychologist.

Assistant Psychologists: Assistant Psychologists have completed an Undergraduate Degree in Psychology and are now assisting a qualified Psychologist in order to gain further experience. They can deliver basic therapeutic interventions under supervision. Once they have gained experience in a range of settings, they can then apply for a place on the Doctorate in Clinical Psychology to become a Clinical Psychologist.

Clinical Psychologists: Clinical Psychologists have completed an undergraduate degree in Psychology, work experience in a range of different settings as an Assistant Psychologist, potentially a Maters or Post graduate diploma in mental health and then a 3 year Doctorate in Clinical Psychology. Once qualified as a Clinical Psychologst, they can then provide various talking therapies for people who have mental health problems. They tend to work with clients with a wide range of mental health problems, whereas Counselling Psychologists tend to work with clients who have milder difficulties.

Counselling Psychologists: Counselling Psychologists have completed an undergraduate degree in Psychology, work experience in a range of different settings and then a Doctorate in Counselling Psychology. Once qualified, they can use therapeutic interventions to support people experiencing difficulties in their lives.

Family Therapist: Family Therapists work with families and couples to help improve their relationships and mental health. To become a Family Therapist, you generally need to have a professional qualification already, such as Mental Health Nurse, Psychologist, Social Worker, Occupational Therapist, etc. You can then complete a 3-4 year part-time course in Family and Systemic Psychotherapy.

Cognitive Analytic Therapy (CAT) Practitioners: CAT is a type of therapy that focuses on the relational patterns that contribute to mental health difficulties. To become a CAT Practitioner, you generally need to have a professional qualification already, such as Mental Health Nurse, Psychologist, Social Worker, Occupational Therapist, etc. You can then complete 2 years study to become a Cognitive Analytic Practitioners and a further 2 years study to become UKCP Accredited CAT Psychotherapists.

Psychiatrists: Psychiatrists are medical Doctors who have specialised in Mental Health and can assess, diagnose and treat mental health problems with medication. To become a Psychiatrist, you need to complete a 5-year degree in medicine (recognised by the General Medical Council GMC), a 2-year foundation programme of general training, and a 6-year specialist training programme in psychiatry.

Motivational Interviewing and CBT for Substance Misuse

I worked in a Substance Misuse service for 6 months, using mainly motivational interviewing and Cognitive Behavioural Therapy. This is an example case to illustrate the approach we used. I have shared it with the clients consent and all details have been anonymised.

A homeless man came to the Substance Misuse Service for assessment. He reported struggling with alcohol use, depression and suicidal thoughts.

I completed the assessment, which took about an hour. We discussed why he’d come in, his substance misuse amounts and frequency, previous convictions, social issues and housing, family (especially details of any children who may be at risk), mental health, physical health, prescribed medication, etc. It also involved completing a risk assessment (eg risk of self neglect, suicide, harm to others, etc) and an initial care plan.

It was important to use Motivational Interviewing skills to during this assessment to encourage change. I’ll explain this in more detail later.

At the end of the assessment, he was asked to complete a urine drug screen and breathalyser.

His assessment indicated that he was physically dependent on alcohol. This means that if he stopped suddenly then he would be at risk of having a seizure (and in some cases people have died from this). I therefore advised him to keep drinking, especially if he was starting to experience shakes, and that he would have to reduce the alcohol gradually (generally by 10% every couple of days).

I discussed his assessment with the rest of the multi-disciplinary team (nurses, psychiatrists, social workers, occupational therapists and psychologists) at the allocation meeting. The client was assigned to the alcohol drop in service; this meant that he would come in once a week during drop in hours for motivational interviewing. After a couple of weeks I was then assigned as his keyworker and continued to work with him on a one-to-one basis.

The aim of Motivational Interviewing was to develop a discrepancy between the person’s current situation and where they want to be. By heightening their ambivalence you can encourage change.

One technique I used is the decisional matrix. This involved asking the client to identify the advantages of staying the same, the disadvantages of staying the same, the disadvantages of changing and the advantages of changing. It was helpful for the client to see that there were many more positives to changing, compared to staying the same.

Another technique was to ask the client to rate their current physical/mental health on a numerical scale and then ask them what it would take to increase that rating by 1 or 2 points. This encouraged the client to think of ways of changing. By coming up with the suggestions himself, he was more likely to accept them compared to being told by someone else. For example, he is more likely to accept his own suggestion ‘I guess I would feel better if I quit smoking’ compared to me saying ‘you should quit smoking’.

It was also important to use the elicit-provide-elicit technique when providing information in to avoid resistance. This is where you ask the person what they know about a topic, then ask permission to give them a bit more information about it, then afterwards elicit it again by asking them how they understand what you’ve just told them.

Throughout the session I used summaries to emphasised the reasons he had given me for wanting to change and encourage ‘change talk’. I also used reflections to manage any resistance. For example, when he stated ‘my family keep nagging me about my drinking’, I reframed it by reflecting ‘so you’re family care about you a lot and are concerned about you’. Or when he stated ‘I’ve tried treatment before and it hasn’t worked’, I reframed it as ‘you’re persistent because it means a lot to you’. You can also used amplified reflections, for example if a client stated ‘I don’t want to give up methadone’, you could amplify it by reflecting ‘so you want to stay on methadone for the rest of your life’, in order to get them to acknowledge ‘well, no I guess not’.

Through Motivational Interviewing I was able to support the client to gradually reduce his alcohol use, to the point where we were able to put him on the waiting list for a detox. I explained that the Detox was the easy part and the hard part would be remaining abstinent when he comes back out again, back to the same situations, places and people. It was therefore important to have some Relapse Management sessions (based on Cognitive Behavioural Therapy) before the Detox.

The Relapse Management sessions involved using Socratic dialogue; informational questioning, active listening (using reflections), summaries and analytical questioning. In analytical questioning you ask questions that will help the client come up with the answers themselves eg ‘on the one hand you say that you think alcohol will help but on the other hand you say that you feel depressed afterwards; how do you make sense of that?’ will lead the client to realise ‘I guess it actually doesn’t help’.

We also focused on identifying and adjusting his automatic thoughts, underlying assumptions and core beliefs (see previous blogs on CBT for an explanation of this). I explained to him that his thoughts and evaluative judgements mediate between stimuli and his emotions or behavioural response. It is not the event that makes him feel depressed but his evaluation of the event; for example, thinking that not being able to get him a job makes him a failure.

He was repeatedly asked to rate on continuum scales (see previous blog) and keep a positive data log as homework. We looked at goal setting and problems solving as well as how to manage high risk situation (eg if in situations with alcohol present), crisis plans (for what to do and who to contact if at risk of drinking) and lapse chains (to determine factors contributing to any lapses he has). I also explained to him the difference between lapses (one or two instances of previous behaviour) versus relapses (going completely back to the previous behaviour) and explained that lapses don’t have to lead to relapse.

Along with the one-to-one therapy sessions, I was responsible for completing continual risk assessments, focusing on the suicidal thoughts and any protective factors. I assessed if they were constant or fleeting and whether he had any intent or plans.

I was also responsible for helping him find housing by writing a letter to the council, helping him find employment by referring him to our employment specialist and liaising social services regarding his daughter. We always inform social services if a child is involved. I explained to him that, although many people worry about social services finding out, they will actually see the engagement in treatment as a good sign because you are getting help. They will always work with families to try and help them and only take children away as a last resort.

I also encouraged him to join in with the service’s groups, including the gardening group, so that he could meet other people in recovery and start engaging in pleasurable activities again (people with depression often cut these activities out of their life over time).

After a successful Detox, he went to rehab. When I left the service he had been sober for 3 months, had improved mood, no suicidal thoughts, had found housing and was completing training (to improve the likelihood of employment). I was glad that I was able to see the case through, as often I have to leave the placement half way through working with someone. It was rewarding to see how far he’d come.

Quick overview of Motivational Interviewing

Motivational Interviewing (MI) is a therapeutic technique that healthcare professionals can use when supporting clients to make changes in their life. This can include doctors supporting patients to stop smoking or psychologists helping clients to engage in therapy. The approach involves exploring and heightening ambivalence about change to help the client move forwards.

The Spirit of MI:

Motivational interviewing is a collaborative approach where the professional honours the client’s autonomy. They are there to guide the client rather than directing or following them. They never tell the client what to do unless specifically asked for your suggestions.

Providing information using the Elicit Provide Elicit sequence:

If you lecture someone about the changes that they need to make, they probably won’t listen. They will probably just shut down or start arguing with you.

It’s much more effective to first check what they know about the topic (Elicit), so that you can be sure that you are only providing them with new information, and ask their permission to tell them more, so they have agreed to listen before you start talking.

When giving advice (Provide), you should keep it neutral, accurate and brief, for example stating ‘you might consider….’ or ‘other people have found that…’.

After giving them information, you can then ask them what they think about this or if they can summarise it back to you (Elicit) . This is to ensure that they have properly understood what you’ve said.

This whole process is know as the ‘Elicit Provide Elicit’ sequence and it tends to be very effective:

Elicit: Checking what they know.
Provide: Give neutral information with permission.
Elicit : Checking what they’ve understood.

 The 4 underlying principles:

 1.    Express empathy through Reflections and Summaries:

Reflections: The professional will often repeat, rephrase or paraphrase what the person has said back to them to show that they have understood. It’s especially important to reflect any ‘change talk’, which is where the person expresses the Desire to change, Ability to change, Reasons to change, Need to change or Commitment to change (DARN-C); reflecting change talk will encourage them to talk about this more.

Summarise: The professional will also summarise what the client has said as a way to encourage them to talk about certain parts more and also to check they have understood correctly. They will also ask the client ‘Is there anything I have missed?’ as part of checking the therapeutic alliance.

 2.    Developing the discrepancy between the current situation and their desired situation:

Developing a discrepancy between the current situation and the desired situation often helps motivate the person to start making changes. For example, ‘I have health problems, no partner and little money as a result of smoking’ vs ‘I want to be able to start running again, find a partner and save up money for a house’. Clients may even be asked to draw out two potential futures: one future where they managed to make changes and one future where they continued with their current behaviour.

Professionals can also use ratings and decisional matrix to help develop discrepancy:

Developing Discrepancy using ratings:
They might ask the client to rate the current situation (eg their physical health) on a scale of 1-10, with 1 being the worst it could be and 10 being the best it could be.
They would then ask ‘what would have to happen for the rating to be increased by 1-2 points?’ This encourages the client to generate ideas about small steps they can take towards their goal. It is always more effective for the client to hear themselves say it, rather than hearing it as a suggestion from someone else. They are less likely to be resistant to their own suggestions.

Exploring ambivalence using a decisional matrix:

Clients may also be supported to complete a ‘decisional matrix’, which is a 2×2 grid where they consider both the pros and cons of making the change and the pros and cons of continuing with the current behaviours. The client is supported to not only look at the number of pros and cons in each section, but also consider the weighting of each item; for example, there may be 10 cons, but they may all be outweighed by 2 more significant pros. This exercise also gives clients the opportunity to openly discuss the barriers to making changes eg they might get less support from their family if they start to recover.

3.    Avoid confrontation and roll with resistance rather that opposing it directly

Resistance can include disagreeing, discounting, interrupting, sidetracking, unwillingness, blaming, arguing, challenging, minimizing, pessimism, excusing or ignoring. When clients respond with resistance, its usually a signal that the professional should adjust their approach. They should avoid arguing for change or responding direct opposition and ensure that new perspectives are being invited but not imposed.

The client is the primary resource in finding solutions, so the professional will prompt them with questions like:

‘What do you think is the first step?’
What do you think you will do?
Where do you go from here?
What are your options?
How are you going to do it?
How will things be better for you when you change?
‘How would your life be different if you achieved this goal?’
Suggest with permission SMART goals.

4.  Support self efficacy and optimism for change

The professional should model optimism and confidence in the client’s ability to change. They can also provide affirmations and praise when the client manages to take small steps towards change. Sometimes even turning up to the session can be a big step or sign of commitment. However, it’s important that any praise is tailored to the client’s presentation and personality, so that this does not come across as patronising.

I will add some worksheets and videos with more information about motivational interviewing soon.

An average day on an Eating Disorders Day Unit

8.45am: Clients arrive at the unit and have their weekly weighing.

9.00am: The clients and staff eat breakfast together. Each client’s meal plan is written together by the client and dietician. It is important that staff measure out juice/cereal/butter/etc accurately to ensure that each client gets the appropriate calorie intake. Clients are very aware if they have been given too much and this can cause conflict, especially as meals are generally a very stressful time. Staff try to distract clients by talking about other topics and not discussing the food, unless prompting is required.

9.30am: Post meal reflections in the lounge. Clients discuss how they found breakfast and any difficulties they experienced over the weekend. Clients are encouraged to stay for half an hour after breakfast, to avoid purging.

10.15am Psychological Skills session for clients to learn ways of managing their anxieties and issues associated with their eating disorder. There are also Health and Wellbeing, Self-esteem and Family/Systemic groups during the week. Some clients have individual or family sessions.

11.15am Snack time

11.25am Key working sessions and client reviews.

12.45pm Lunch time. This is generally more tense than breakfast as it is a bigger meal.

1.30pm Post Meal reflections

2.10pm Art therapy group. Clients are given the topic ‘Road to Recovery’ and allowed to use any media they want. They all really seem to enjoy the group and it’s interesting to see their interpretations (see photo).

3.30pm Snack time

3.45pm End of day reflections.

4.00pm Clients go home. Their evening meal is planned in advance.