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CONTEMPORARY FAMILY THERAPY
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ideas about how illness is expressed, and that "both experience and
popular conception are conditioned by the prevailing structure of social relations" (Singer, 1989, p. 1199). Forms of illness therefore come
to embody peoples' experience of material conditions and social relations, a process known as somatization (Kleinman, 1986; ScheperHughes & Locke, 1986). Following Kleinman (1986, p. 174), "persons
who are at greatest risk for powerlessness and blocked access to local
resources are most likely to somatize." Similar arguments are given
by proponents of "critical theory" (Habermas, 1986; Scambler, 1987;
Mishler, 1984). They view "medical colonization of the lifeworld"
the lifeworld being the social context of background assumptions,
convictions and categories within which culture, social integration
and personality are sustained and reproducedas explaining why clients and providers tend to exclude psychosocial factors from their explanations for suffering and distress.
Therefore, in societies where the structure of social relations perpetuates a culture of somatization, it can be assumed that significant
numbers of people wrongly believe they are suffering from medical
disease and are inappropriately given medical treatment. With the
inclusion of mental health services, their distress is reconceptualized
as being of psychosocial origin, and appropriate interventions are
made at both primary and secondary levels of prevention. This results
in changes in hospital admission rates (Derkson, 1986), utilisation
patterns (Goldberg, Krantz & Lock, 1970) and costs (Borus et al.,
1985).
This interpretation is particularly appropriate in Soweto (which
is short for "south western townships"), where the present research
was conducted. Soweto is home to some 1.75 million people, most of
whom are African members of the working class and subject to the
dual forces of racial discrimination and economic exploitation entrenched in the structural and cultural organization of South African
society. The township has a poorly developed infrastructure and most
of its inhabitants contend with long hours traveling to and from work
and overcrowded living conditions, as well as disruptions by the state
of attempts at empowerment through collective social and political
action.
These conditions place Soweto residents at high risk for somatization. In a survey of patients presenting at one of the township's
twelve primary health care clinics, Seedat and Nell (1989) found that
of 327 consecutive presentations, 17% had mild psychological distress.
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MOHAMED SEEDAT, ALEX BUTCHART, AND VICTOR NELL
of the Training
Program
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CONTEMPORARY FAMILY THERAPY
about what counseling means), and the most respected (not necessarily in terms of official status and rank).
In this way 24 trainees were selected from the 50 volunteers.
However, in response to requests from the clinic administration to
reduce the number of trainees because of service pressures, 18 entered the training programme. They were randomly assigned to one
of two training groups, both of which consisted of nine trainees and
two facilitators. Training sessions were held on a weekly basis at the
Psychological Distress and Training Room in a primary health care
clinic, and each was approximately three hours long.
Creating organizational support. Before training commenced, an
attempt was made to create organizational support for the program.
This involved establishing close ties with managerial staff of the
clinic system, and giving them insight into what the program entailed. Two matrons, well known to their colleagues, were invited to
participate with the trainers in a microcounseling based Lifeline
training course for telephone counselors, and they remained sympathetic to the program. However, ultimate power in this clinic system
is vested in the senior nursing manager and her head office colleagues. This staff was invited to preview some of the videotaped roleplays that are part of the training program. These presentations were
observed with passive interest, and the steps taken by the trainers to
secure high-level organizational commitment were ineffective.
Training format. Each session of the microcounseling and family
therapy intervention modules concentrated on a single skill. Videotaped role-plays of bad counseling (asking closed rather than open
questions, inaccurate summarization, etc.), were followed by demonstrations of correct techniques. Prior to viewing the videotapes, but
after having each skill described and explained to them, trainees
practised the skills in small groups while being video-taped. They
then reviewed their own role-plays, followed by the training videotapes, and practised the skills once again in their groups. The effectiveness of this approach has been demonstrated (with the training of
graduate level psychologists), by Kramer and Reitz (1980), who used
video playback to enhance trainees' self-awareness during a two-year
training program, and by West, Hosie and Zarski (1985), who used
simulated families in the training of novice-level family therapists.
Trainees often requested discussions about personal problems
and issues related to patient care, and were encouraged to introduce
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MOHAMED SEEDAT, ALEX BUTCHART, AND VICTOR NELL
such material into the role-plays. For example, one nurse said that
when working with clients who complained of problems such as headache and stomach pains, she would at times find "nothing wrong" on
physical examination, and feel resentful and angry toward the client
for wasting her time by "pretending" to be sick. This situation was
simulated, and the nurse was encouraged to probe the life issues surrounding the client's complaints in a sensitive and caring way.
Through this she learned to interpret such complaints as non-verbal
messages about the client's difficulties in other contexts, and her feelings of resentment toward such clients were eroded. By dealing with
such issues during role-plays it was hoped the nurses would begin to
appreciate the value of counseling in relation to issues that were of
immediate significance to them. However, to prevent training sessions being swamped by personal issues (and in effect converting
them into group therapy sessions), the four-day experiential workshop described above was held midway through the program.
Two sets of measuring instruments were developed to evaluate
training outcome.
A paper and pencil test. This tapped perceptual, observational,
and conceptual skills. It consisted of^ multiple-choice questions and
questions requiring short paragraph answers. These were completed
after trainees had viewed a series of videotaped family therapy segments, and the questions were about interpersonal sequences and
events depicted on the videotapes.
Family therapy role-plays. The influence of training on practical skills was assessed through role-played family therapy sessions in
which unit staff simulated family behavior for a nurse acting as therapist. The role-plays were videotaped, and rated by two skilled family
therapists. Both raters were blind to the allocation of nurses to the
experimental (trained) or control (untrained) groups.
It was originally hoped that training outcome would be measured
by having each trained nurse counsel a family that included a brain
injured person. Concerted efforts were made to recruit such families,
including home visits by health psychology unit fieldworkers. However, only one of the 10 families who agreed to come presented for
four out of eight planned intervention sessions, and one for a single
session only (the brain-injured person was killed in a fight before the
family could return for the second session).
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CONTEMPORARY FAMILY THERAPY
Rating scales. Two sets of rating scales were used. The first measured the presence or absence of therapist functions and their sequencing. The second measured levels of competency for each function. The scales were finalized in consultation with the raters, who
agreed they were appropriate to distinguishing between trained and
untrained nurses, and to evaluating the levels of competency demonstrated by each nurse (copies of these scales are available from the
authors).
Control Group
A control group was assembled in cooperation with the chief matron of a city hospital. It consisted of nine nurses matched to the
trainees in terms of social and educational background, nursing experience, the type of work they did most often, level of seniority, and
workload. All participated voluntarily. While all nine conipleted the
paper and pencil examination of conceptual skills, only seven participated in the family therapy role plays.
RESULTS AND DISCUSSION
Paper and Pencil Evaluation
The results of the observational and conceptual skills examination, for trained and untrained nurses, revealed no significant differences between the scores obtained by the two groups. It is hypothesized that this procedure lacked criterion validity. This is despite the
fact that questions were framed in language appropriate to the
nurses' educational level (as demonstrated by pilot testing), and were
judged to have face validity by an experienced trainer in family therapy. That the issue is one of criterion validity of the test rather than
the absence of the training effect is demonstrated by the results of the
other rating procedures.
Role Play Evaluation
Interrater reliability. The ratings of the two family therapists
who observed the videotaped role-plays were correlated, and robust
interrater reliabilities occurred. The scale measuring presence or absence of therapist functions yielded the lowest interrater reliability (r
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MOHAMED SEEDAT, ALEX BUTCHART, AND VICTOR NELL
= .65; p < .001). For the remaining five scales correlations ranged
between .7855 and .92 (for all five scales p < .0001).
Sensitivity to therapist functions. Figure 1 shows skill levels in
terms of sensitivity to therapist functions, as indicated by the presence or absence of each function. Clearly, the simple presence or absence of a therapeutic function does not imply that a trainee is more
or less likely to exert a therapeutic infiuence. However, it is reasonable to attribute systematic differences in the frequency with which
various functions were performed by nurses in the trained and untrained groups to the training.
For both groups the most commonly omitted function was activation, which involves getting family members to talk to each other
about the problem. During activation the therapist stops being the
center of conversation, and so can observe interaction patterns between family members, thus gaining useful diagnostic information. It
can also be used to disrupt rigid coalition patterns when the therapist
encourages the participation of family members who usually remain
passively involved (e.g., asking a "silent" father to show how he could
support mother in her attempts to convince their teenage son that he
should not get drunk every night). This function was absent from the
role plays of all nurses in the untrained group, and 56% of the trained
group. Socializing was the next most commonly omitted function: approximately 30% of nurses in both groups did not perform it. Contracting was omitted by 24% of the trained and 44% of the untrained
nurses. Greeting and problem identification were displayed by all
nurses in both groups. All members of the trained group engaged in
goal setting, which was omitted by only one member (14%) of the
untrained group.
Level of skills. Figure 2 compares competency levels by therapeutic function for the trained and untrained groups. Overall, Figure 2
indicates that the trained group showed higher levels of competency
than the untrained group on all functions except for socializing,
where untrained nurses obtained a slightly higher average than
trained nurses. Comparisons between the two groups in terms of percentage of therapeutic functions omitted (Fig. 1) and competency
levels by function (Fig. 2), converge to indicate that training sensitized the trained group to the logic of family therapy, and, at a practical level, expanded their repertoire of skills. Table 1 summarizes
some of the qualitative differences between groups on each therapeu-
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CONTEMPORARY FAMILY THERAPY
FIGURE 1
Percent of Trained and Untrained Nurses who Performed
Therapeutic Functions.
100,
90 _
p
e
r
c
e
n
80 _
70 _
60 _
50 _
Trained (N = 9)
t
40 _
o
f
Untrained (N = 7)
30..
20 _
10.
0
1
Therapist Function
Key to therapist functions:
1. Greeting
2. Socialising
3.
4.
5.
6.
Problem Identification
Activation
Goal Setting
Contracting
tic dimension, and is based upon notes made by the raters. Table 1
shows that while trained nurses demonstrated a broader repertoire of
therapeutic functions and greater flexibility than the untrained
group, how these were executed fell short of the ideal.
Greeting and socializing. Trained nurses more consistently
greeted all family members than did untrained nurses. However,
their style of greeting shared some of the stiff and contrived quality
shown by untrained nurses. Untrained nurses engaged in socializing
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MOHAMED SEEDAT, ALEX BUTCHART, AND VICTOR NELL
FIGURE 2
Trained and Untrained Nurses' Average Competency Ratings for
Therapeutic Functions.
Trained (N = 9)
Untrained (N = 7)
0.0
2
Therapist Function
Key to therapisc functions:
1. Greeting
2. Socialising
3. Problem Identification
4. Activation
5. Goal Setting
6. Contracting
for longer than the trained nurses, and received a higher competency
rating for this function. This suggests that untrained nurses were less
certain as to how to conduct the interview, because they did not have
the opportunity to expand their repertoire of interpersonal skills, or
complement the traditional role of nurse with the facilitative role of
therapist. Lacking these skills, they may have sought refuge in socializing, masking their uncertainty concerning how to deal with the
families' dilemmas and requests for help.
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CONTEMPORARY FAMILY THERAPY
TABLE 1
Qualitative Composite Descriptions of Competency Levels by
Function for Trained and Untrained Groups
Trained Nurses
Untrained Nurses
Greeting
Most greeted in a spontaneous
Greeting tended to be stiff and
way that suggested a real
highly formalized, and appeared
interest in the family and
to inhibit mutual participation
willingness to hear their point of by creating a sharp divide
view. However, two nurses
between the nurse and the
adopted contrived, rigid style
family.
that parodied an image of slick
professionalism.
Socializing
Tended to socialize with only one Vacillated between socializing
family member, thereby
with one family member and the
excluding others, and appeared
entire family, often at a
to have difficulty in extending
superficial level. Frequently,
this phase. Consequently, nurses nurses seemed to find difficulty
entered the Problem
terminating this phase, and
Identification phase without a
often reverted to socialising
clear idea of the family's life
when sensitive and threatening
context.
issues were introduced.
Problem Identification
Partially succeeded in exploring Problems were explored in a
the problem in an open-ended
closed way, most questions being
way that included all
directed to the dominant family
participants. However, some
member. Hence, nurses became
nurses tended to ally with the IP trapped in the family's scenario
against the family, thereby
of the problem, and reinforced
alienating asymptomatic family
failed solutions. Tended to ally
members by implicitly blaming
with the family spokesperson
them.
against the IP.
Activation
Those who attempted activation
Made no attempts to activate
made the transition in an
families.
uneasy and abrupt manner,
usually initiating conversations
between only two participants.
1,
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MOHAMED SEEDAT, ALEX BUTCHART, AND VICTOR NELL
Trained Nurses
Untrained Nurses
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MOHAMED SEEDAT, ALEX BUTCHART, AND VICTOR NELL
difficulties obtaining time off work and traveling to the clinic). Untrained nurses frequently failed to exchange telephone numbers and
confirm interview dates, possibly because in the medical model it is
unnecessary to have the same provider work with the same patient
on different occasions, and therefore it is not contradictory to arrange
a follow-up without specifying these details.
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CONTEMPORARY FAMILY THERAPY
CONCLUSION
This attempt to teach family therapy skills to primary health
care nurses resulted in an inadequate outcome: although the training
itself partially succeeded, the medical and social context remained
resistant to the concept of integrating psychology and biomedicine.
This partial failure can nonetheless be viewed as making a useful
contribution to the introduction of psychology into primary health
care, insofar as it uncovers the degree to which "soft" treatment options (such as family therapy) are unlikely to prosper as long as the
macro-context, at both organizational and ideological levels, selectively reinforces the use of "hard" diagnostic and treatment options.
These lessons offer a sufficient basis for modification of the training program, together with renewed attempts to create organizational
reinforcers, for it to be tried again and evaluated in terms of costoffsets to patients and providers.
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