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FAMILY THERAPY IN PRIMARY

HEALTH CARE: SKILLS TRAINING AND


OUTCOME EVALUATION
Mohamed Seedat
Alex Butchart
Victor Nell

ABSTRACT: Some of the theoretical tenets of family therapy such


as emphasis on the activation and utilization of existing family resources and the importance it accords to context appear to have a
good fit with primary health care's commitment to empowering individuals in their struggle against ill health and the circumstances in
which it occurs. This paper explores the possihility of teaching a prohlem-solving approach to family therapy to nurses in a South African
primary health care system. Training consisted of conceptual, pragmatic, and self-growth exercises, and trainees' conceptual and performance skills were compared to the skills of a group of untrained
nurses.
Mohamed Seedat, MA, is director. Living After Murder Program, Roxbury Comprehensive Community Mental Health Center, 435 Warren Street, Roxhury, MA
02368, USA.
Alex Butchart, MA, is deputy director. Health Psychology Unit, Department of
Psychology, University of South Africa.
Victor Nell, PhD, is director. Health Psychology Unit, Department of Psychology,
University of South Africa.
Reprint requests should he addressed to Alex Butchart, MA, Health Psychology
Unit, Department of Psychology, University of South Africa, PO Box 392, Pretoria,
SOUTH AFRICA 0001.
We thank Bukelwa Selema, co-trainer on the program, for her contrihutions to
joining effectively with the nurses and enriching the experiential process. We also
thank Dr. P.J. Beukes, Dr. J.H. Olivier, Dr. G.M. Louw, Matron L.C. Langley and
other staff in the Soweto primary health care system for their support. In particular,
we are grateful to nursing sisters Martha Nkoane and Millicent Matomela, who roleplayed clients on the videotaped training modules. We are also grateful to Edcent Williams, who was one of the videotape raters, and Mike Spruce, Ricky Snyders, Nico
Cloete, Ricky Mauer, and Brenda Radehe for their inputs at various stages of designing
and implementing the programme.
Contemporary Family Therapy 13(2), April 1991
1991 Human Sciences Press, Inc.

143

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CONTEMPORARY FAMILY THERAPY

This paper describes an attempt to teach basic skills in family


therapy to primary health care nurses in Soweto. It assumes that including psychological services at a primary health care level will help
meet an under-provided for set of needs, and contribute to the World
Health Organisation's goal of Health for All by the year 2000.
Research in the Netherlands shows that the inclusion of psychological services in primary health care appears to raise the quality
and lower the costs of health care. In areas where psychological services are available, mental health hospital admissions have been reduced from the national rate of 2.4 to 1.1 per 1,000 population (Derkson, 1986). In the United States, Goldberg, Krantz, and Locke (1970)
examined the effects of short-term outpatient mental health treatment on the use of general medical services by 256 patients in Washington DC. The number of patients seen for non-psychiatric medical
services decreased by 13.6%, and there was a 15.7% decrease in the
number seen for laboratory and X-ray procedures. These changes
were associated with reduced costs to clients and providers.
Focusing on the economic benefits of introducing mental health
services, Borus and others (Borus, Olendzki, Kessler, Burns, Brandt,
Broverman, & Henderson, 1985) examined the medical records of 400
patients for a five-year period. Patients using ambulatory mental
health care facilities made less use of medical services than patients
who did not use such facilities. They concluded that:
By the second post-treatment year, the untreated group used
1.53 as much non-psychiatric medical care as the treated
group, and averaged more than $94 per year in increased
non-psychiatric medical costs compared to the treated group
(Borus et al., 1985).
These data support the assumption that including mental health services at a primary health care level may reduce the number of hospital admissions, and the costs born by clients. However, they do not
explain these effects.

DISEMPOWERMENT AND AGENCY


One explanation is taken from the perspective of critical medical
anthropology. This is that individual experience is fitted to popular

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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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and 10% a severe level of psychological distress, (i.e., psychological


problems constituted two-thirds or more of the motivation for that
clinic visit). When passive observation of nurse-patient interaction
was supplemented by an active interview in a sample of 113 cases, an
estimated 19% of presentations had mild psychological distress,
11.8% moderate distress, and 3.6% severe distress. While comparable
data for other parts of South Africa are not available, a somatization
rate of between 27 and 34 percent represents a significant proportion
of patients presenting at primary health care clinics, indicating that
the provision of psychological services will meet an important local
need.
However, this emphasis on social determinism suggests individuals have no role to play in perpetuating their distress. This implies
that psychological interventions (insofar as they "work" by altering
how clients conceptualize the origins and maintenance of problems),
cannot contribute to overcoming disempowerment and so are irrelevant to primary health care. But, many writers (Butchart & Seedat,
1990; Hayes, 1989; Shotter, 1984; Straker, 1989) argue that "situations do not create people, people create situations" (Miller, 1989, p.
5). One of the ways in which social situations are reproduced is
through the agency of individuals whose ideas about themselves in
relationship to others and the environment reflect how their common
sense has been shaped by the dominant ideology. In South Africa, the
dominant ideology shares the Western world's depiction of people as
organisms whose behaviour is determined by their circumstances and
their internal mechanisms or characteristics. Therefore, when people
who have assimilated this ideology explain distress, they attribute its
origins primarily to environmental factors and decontextualized inner forces such as 'the self or 'illness'.
Explanations of this form obliterate the idea that people are the
products of their own and others' activity, and therefore partially responsible for it and its consequences. Hence, people who use such explanations are partially responsible for their own disempowerment. If
this is accepted, it is evident that a context for re-empowerment, in
relationship both to presenting problems and the wider context, can
be built through psychological interventions that facilitate movement
in how clients view themselves, from objects and victims, to agents.
Because most theories and techniques of family therapy share
some of these assumptions, albeit without acknowledging the role of
ideology, it Was decided to explore the appropriateness of teaching it
to nurses in a primary health care context.

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MOHAMED SEEDAT, ALEX BUTCHART, AND VICTOR NELL

FAMILY THERAPY IN SOUTH AFRICA:


PROFESSIONAL AND IDEOLOGICAL
CONSIDERATIONS
The training of family therapists has similarities to the ancient training of samurai warriors . . . Techniques of survival
in comhat. . . are startlingly close to the techniques of family
therapy . . . To become a master he (the samurai), had to
train as a warrior for three to five years. Then, having hecome a craftsman, he was required to abandon his craft (Minuchin & Fishman, 1981, pp. 3-4).
Although family therapy defines itself as a specialized mode of
intervention developed by and for society's elite (as suggested by the
above epigraph), some practitioners, such as Elkaim (1982), have
taken steps to democratize its technology and acknowledge that it
should not be viewed in a sociopolitical vacuum. But such initiatives
have not infiuenced the discipline in any significant way, as suggested by a survey of all articles published between January 1980
and July 1989 in Family Process, Contemporary Family Therapy (previously called the International Journal of Family Therapy), and the
Journal of Family Therapy. Only two articles (in the Journal of Family Therapy), present evidence supporting the feasibility of teaching
family therapy skills to non-experts (Street & Treacher, 1980;
Jenkins, 1984).
In this light it seems inappropriate to try and include family
therapy in primary health care. It is therefore necessary to examine
some of the values and interest structures that inform the theory and
practice of family therapy in South Africa, and so explore its fit with
primary health care.

Family Therapy and Primary Health Care in South Africa:


What is Their Fit?
Almost all South African psychologists are drawn from the ranks
of the dominant white minority (Prinsloo, 1989), and most family
therapy training courses are tailored to creating professionals who
will serve the needs of middle- and upper-class clients. Because such
courses pay scant attention to the interplay between ideology and
psychology, few family therapists refiect upon how their ideas about
psychopathology and family functioning may tacitly reproduce con-

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CONTEMPORARY FAMILY THERAPY

cepts of cultural determinism and ethnic separatism (Nicholas, 1987).


These naturalize race and class divisions by depicting them as unchangeable forms of social organisation, rather than socially constructed categories which serve the interests of the dominator.
Apartheid, like the colonial systems from which it is descended,
perpetuates itself through relationship patterns that are part of the
fabric of everyday life. People play out their ascribed roles of oppressors and victims, often subtly and less frequently by open coercion, but in all cases by confining and being confined to a narrow
world of prescribed ideas and prohibitions (Boonzaier, 1989; Bulhan,
1985). Within this world, belief systems and statutory provisions interact to exaggerate differences, sometimes trapping naive professionals wishing to "bridge the gaps" between different sectors of society into ethnicity and sectarianism. Such apparently "harmless"
perceptions of cultural differences readily assume an oppressive role
when professionals reify the racial categories that state legislation
imposes upon people ("Blacks", "Whites", "Coloureds" and "Asians"),
by constructing the belief that they dictate a significant modulation
of therapeutic style and content (Seedat & Nell, 1990). These concepts
of ethnic exclusivity and incompatibility are also entrenched in the
ethical principles of the South African Institute for Clinical Psychology, the implications of which are addressed by Swartz (1988).
Given these considerations, the question as to whether family
therapy has a place in primary health care must be answered ambivalently. To claim it does challenges the ideology of ethnic separatism
which pervades the discipline, by refuting the assumption that race
differences dictate different therapeutic styles. But, to acknowledge
the place of family therapy in primary health care may also bolster
the tendency of mainstream family therapists to locate problems
solely within the boundaries of the family. This can defiect professionals and ordinary people from confronting the wider context of oppression and exploitation, thus reinforcing existing social and political inequalities.
However, because the attitudes of professionals and ordinary people are part of the problem (and its solutions), the benefits of acknowledging the place of family therapy in primary health care seem
to outweigh the risks. It may increase the scope of what professionals
consider to be appropriate domains of practice, for example, by encouraging the formation of interest and pressure groups to lobby for
the provision of funding to engage in primary health care, which, unlike private practice, demands that professionals be paid a salary. It

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could also sensitize organizations and professions involved in primary


health care to psychology's role in service provision, thus enhancing
interdisciplinary cooperation and maximizing the potential benefits
available to clients. It also would serve to induce self-criticism among
the ranks of psychologists, by forcing them to evaluate the discipline's
role in society.
It is less easy to defend the argument that introducing family
therapy into primary health care feeds into the risk of pathologizing
families in a pathological society. However, although mainstream
family therapy tends to restrict its interventions to individuals and
the family unit, it does offer interpretive and interventive skills that
allow practitioners to co-create an awareness of how people may be
contributing to the maintenance of their own distress and disempowerment, when combined with understanding on the practitioner's
part of how epidemiological patterns and risk factors reflect race and
class divisions in South African society (Anderson & Marks, 1989; de
Beer, 1984; Nell & Brown, 1989).
Also, the reality constraints inherent in the townships and locations most often targeted by primary health care (inadequate housing, poorly developed health, and social welfare infrastructures),
make it important to utilize all resources within reach of those who
present for treatment. Family therapy's emphasis on mobilizing therapeutic resources within the client system makes it well equipped to
do this.
Last, the concepts of family therapy provide a vehicle by which to
sensitize primary health care workers to psychosocial factors in the
origins and maintenance of individual distress. Teaching family therapy skills to nurses can thus be viewed as one step toward the development of non-medical treatment modalities in the heavily medicalized and cost-intensive South African health care system (Nell,
1989), with benefits for both clients and providers. It was in an attempt to explore whether some of these benefits could be realised that
the present researchers (all trained in family therapy), elected to deliver and evaluate a program aimed at devolving basic skills in family therapy to nursing staff in the Soweto primary health care system.
Before describing this program it should be noted that at least
two other initiatives aimed at increasing the accessibility of family
therapy to all South Africans have been carried out. First, Spruce and
Snyders (1982) describe their attempts to devolve micro-counseling
techniques to psychiatric nurses in a large mental hospital. Training
focused on the development of refiective and empathic counseling

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CONTEMPORARY FAMILY THERAPY

skills, and the goal was to create a climate of psychological care in an


overcrowded and understaffed institutional context. Whereas the present research aims to introduce psychology into primary health care.
Spruce and Snyders' work addresses the levels of secondary and tertiary prevention, and does not examine organizational constraints
upon the introduction of psychological care. Second, the Family and
Marital Association of South Africa (FAMSA), offers some services in
Soweto and other townships. These are focused upon intervening
among families with problems such as divorce, child abuse, and domestic violence. However, FAMSA is a direct service provider, and as
such does not train para-professionals such as nursing staff, meaning
it can only meet the needs of very few clients. Beyond such services as
FAMSA offers, it must be noted that there are almost no existing
mental health care services in Soweto. This is largely because no
posts for mental health care workers exist outside of secondary and
tertiary care psychiatric settings. Because such workers are absent at
the level of primary health care, somatized psychological distress is
neither perceived nor referred for psychological intervention.

NATURE OF THE TRAINING PROGRAM


Content and Structure
The content and structure of the present training program draws
upon Spruce and Synder's (1982) techniques for teaching therapeutic
skills, Ivey's Microcounselling; Innovations in Interviewing Training
(1971), Haley (1978), and also Egan (1982), Le Roux and Snyders
(1981) and Tomm and Wright (1979). Briefly, it consists of the following parts (copies of the detailed program are available from the authors).
Microcounseling. This component consists of six 20-minute videotaped modules that model "good" and "bad" skills in the following
areas: opening the interview, non-verbal communication, verbal following, refiection of feelings, minimal encouragers, and summarization. The introduction and six microcounseling modules were taught
over 21 hours (one three-hour session per week for seven weeks).
Intervention and family therapy. This segment comprises seven
modules and includes an introduction to the use of basic family ther-

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apy assessment techniques such as genograms and sociograms. These


modules also cover an introduction to family systems and interaction,
and the six therapist functions defined by Haley (1978), namely:
greeting, socializing, problem identification, activation, goal setting,
and contracting. As for microcounseling, these were taught over a
period of 21 hours (one three-hour session per week for seven weeks).
Self-growth and experiential work. Integrated with the teaching
modules was a self-growth component. This was a four-day experiential workshop held at a country conference center. Nurses and
trainers refiected upon their own needs, interpersonal styles, and social support networks. The importance of this component was shown
as training proceeded, and increasing numbers of nurses voiced anxieties about burning out due to difficulties integrating the new challenges presented by the training program with routine work and dayto-day domestic pressures. These stresses were exaggerated by the
absence of organizational support for their participation in the program, and at a more abstract level by confiict between the roles of
nurse and therapist. On a more positive note, it was felt by nurses
and trainers that the experiential component created avenues by
which emotional and peer support could be provided, insofar as it
highlighted the existence of psychological and emotional resources for
coping and creating change within the training group itself.
Implementation

of the Training

Program

Selection of trainee nurse-therapists. One-hundred-fifty black


South African nurses participated in a networking exercise that preceded the training program. This was intended to sensitize them to
the social and psychological origins of distress among patients presenting at the clinics. Nurses in this group were asked to volunteer
for the training program, and as there were more volunteers than
could be accommodated, a system of peer selection was used to select
the group for training. Nurses voted for the volunteers they believed
to be most suited for training in family therapy, and candidates were
selected by asking nurses to answer the following question: "If you or
a member of your family had a problem, who among the people here
would you go to to discuss it?" It was assumed that nurses selected in
this way would be those perceived as most competent and confident in
a counseling situation (on the basis of the peer group's own ideas

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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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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

Nurses generally failed to utilize


the opportunities for activation
created by spontaneous
activation within the family.
Goal Setting
While goals were usually linked Goals were set without
to the family's explanations and acknowledging the family's
resources, only one or two family frame of reference, and were
members were incorporated in
shaped by the nurses' biomedical
the planning and execution
explanations and decisions,
suggested by the nurses.
Occasionally one or two family
Overall, goals set were
members were included, but in a
appropriate to broad
way that allied them with the
psychosocial rather than purely
nurse against other family
medical ideas of distress and
members,
intervention.
Contracting
Generally, little concern was
Most often, sessions were
shown for practical issues that
abruptly terminated without a
may prevent or hinder follow-up, contract. The few attempts at
Contracts were usually made
contracting were superficial, and
with the dominant family
not backed up with the exchange
member.
of telephone numbers and
specification of dates.
That none of the untrained nurses made an attempt to activate
the families (see Fig. 1), supports this interpretation. Activation is
the most asocial of the therapeutic functions, and also one which is
dissonant with the controlling and prescriptive role of nurse. It was
also noted by the raters that many trained nurses made only cursory
attempts to socialize. This meant they entered the problem identification phase with inadequate knowledge of the life context and coping
resources of each family member, suggesting that they construed the
concept of "problem solving therapy" in a more concrete and restricted way than the trainers intended.
Problem identification. Here, clear differences emerged between
groups. Untrained nurses asked closed questions and almost without
exception were trapped into confirming the pictures of the problem

160
CONTEMPORARY FAMILY THERAPY

conveyed by dominant family members. They thus drew alliances


with them against the identified patient (IP), and failed to communicate that the ideas and actions of family members contributed to
maintaining their presenting problems. One untrained nurse converted a manifestly social difficulty into a medical problem. Another,
agreeing with the mother that the IP "was not really sick," said:
"Your problem is very minor, I think you can solve your own problem".
In contrast, open ended, and at times even circular-type questions, were used by the trained nurses to contextualize the problem
within the family's ecology of ideas and relationships. However, their
attempts to translate symptoms from the language of disease into
metaphors of the psychosocial context were at times too abrupt and
extreme. For example, in one role play the presenting problem of a
headache was transformed into a call for assistance around the house
within the first few minutes of the interview, and the IP left the interview still asking: "But what can I do about my pains?" Also, in
their enthusiasm to frame presenting problems as functional within
the family, trained nurses tended to created coalition patterns that
were mirror images of those set up by the untrained nurses, and frequently drew alliances with the IP against other family members.
Activation. Inter-group differences in activation were particularly
pronounced. No untrained nurses, and only 46% of the trained nurses,
attempted activation. Those that did attempt to get family members
talking among themselves did so in a forced and rigid way, according
to their own timing, and failed to utilize cues offered by spontaneous
interaction between family members.
Goal setting. Differences in setting goals were less distinct than
for the other skills. Trained nurses were somewhat better than untrained nurses at formulating goals within the family's frame of reference, and implicitly empowered individuals by leaving the responsibility for action with at least one or two family members. In
contrast, untrained nurses implicitly disempowered individuals by reproducing in the goals they set the role of an expert who unilaterally
prescribes a remedy to a passive patient. In one extreme case, an untrained nurse concluded her interview by saying: "When you come
back I will have a solution for you!"
Contracting. When making arrangements for subsequent sessions, nurses in both groups tended to ignore practical issues (such as

161
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.

NURSE ROLES AND ROLE CONFLICT


At one level, this attempt to teach basic family therapy skills to
medically oriented primary health care nurses illustrates the difficulties of altering the attitudes and roles of individuals without addressing the wider organizational context. All nurses entered the
training program with concepts of illness and cure firmly embedded
within the diagnostic-curative model of medical treatment. This allocates to them a prescriptive, objective, and informative role that in
many ways contradicts the logic of psychotherapeutic intervention,
which demands a role that is non-prescriptive, facilitative, intersubjective, and empowering. For example, during the experiential workshop nurses were informally asked to define their roles, and used
terms such as: "health educator", "advisor", "exemplary role model of
healthy living", "leader", "expert", "resource person", "assessor", "caring but professionally distant", "friend", "confidante". All except the
last two of these self-descriptions depict the nurse as an expert whose
specialist knowledge gives her the mandate to unilaterally diagnose
and prescribe solutions.
in contrast, family therapy requires that nurses view themselves
as non-judgemental facilitators, whose role is to mobilize clients in a
way that empowers them to recognize their own role in the maintenance of problems and harness their own potential for the solution of
problems. This requires that nurses develop the fiexibility necessary
to move between the medically defined role of an expert, and that of
the psychotherapist. It is argued that the stress and sense of burnout
described by nurses during the experiential workshop, and the failed
attempt at creating organizational support for the programme, were
due in part to the dissonance of these roles, and the researchers' failure to consider the organizational context when designing the programme (Seedat & Nell, 1990). The trained nurses are currently being tracked to establish how many of the skills they learned are being
used. Preliminary observations suggest these are few, and that most
nurses have reverted to their traditional roles.

162
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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