Struggling to decide on therapy choice? Here’s how to choose between individual or family therapy for real change.
The death of expertise undermines families and therapies.
Key points
- The death of expertise in therapy is an ongoing concern.
- Most clinics let the clients choose which mode of therapy they will receive.
- Therapy choice hinges on who wants, must, and can change.
The death of expertise (Nichols, 2017) has long ago captured the field of psychotherapy. Some second-year students are sure they know more about the practice of psychotherapy than their professors. They are certain that whatever made them feel good when they were in therapy is the correct model, unaware that the point of therapy is for the client to get better, not to feel better.
Perhaps this is related to their having the entire store of human knowledge in their pockets. They’re not impressed with anything an expert can do if their phone can do it, too. And anything the expert claims to do that the phone cannot, like deciding between individual and family therapy, tempts the student to think it’s not an important skill. If it were, there’d be an app for it.
You can “OK, boomer” me if you need to, but the fact is that my generation was constantly humbled by our lack of knowledge. We had to look it up or ask an expert. This created a lifelong sense that there is a lot of knowledge in the library and in the minds of elders. When the store of knowledge is in one’s pocket, it feels like it already belongs to you when you consult it. No humbling is involved.
Read More Here: 5 Valuable Life Skills Often Learned By Those With Complex PTSD
This idea that the client is always right notably leaves the therapist in the clear when it comes to treatment planning and case formulation. In my experience, the client’s view of the problem and of how to address it is typically informed by the patterns that produced the problem in the first place.
Take the irritated parent whose kids learn to tune out and thereby become impulsive. (Impulsivity is often a state where the more mature executive functions are not listened to.) This irritated parent defines the kid as a troublemaker and sentences her to individual therapy.
The doting parent whose kid never learns how to walk off an injury may produce a kid unwilling to take risks, a kid who falls in love with their phone rather than with another human who might reject them. The doting parent may ask for family therapy because nothing is the child’s fault—or responsibility.
When clinicians defer to the client, it’s usually because of a questionable motive. For example, the therapist needs the money and doesn’t want to drive away the client by recommending something that feels painful or awkward. Or the therapist has hangups about aggression, like medical students who balk at cutting someone open, and shudders at the idea of imposing their case formulation on the client. Or, perhaps, the therapist is a parentified child.
A parentified child is one who has been saddled with responsibilities ideally left with parents, but one who is not also given the authority to meet those responsibilities. When one of those responsibilities is to monitor and manage the family’s emotional life, the child often grows up to be a therapist. It is essential to the subjective well-being of a parentified child that the boundaries between children and parents remain vague.
Clear boundaries are good for families and family members (Minuchin, 1974), but clarifying previously vague boundaries causes pain. There’s remorse for living ambiguously for so long; there’s embarrassment about going with the flow rather than providing structure; and there are painful reorganizations of personal identity when the parentified child no longer derives self-esteem from helplessly and ineffectually trying to manage a system with responsibility and no power.
Ironically, the lack of structural clarity that produces behavior problems in families is repeated in therapies where the therapists think they are empowering clients by letting them have their way. I always think of the parents who let their children eat only dessert, certain that the children knew their bodies and what’s best for them.
Individual vs. Family Therapy Decision
All of this preface is just to say that the question of whether to do individual or family therapy has been solved long ago, but to warn the reader that you might not like the solution, and that it requires the sort of triage that is commonplace in medicine but has become politically suspect in psychotherapy.
Most clinics let the clients choose which mode of therapy they will receive. Unfortunately, the death of expertise in therapy has created a culture where a diploma is pursued rather than expertise, and there is consequently a very good chance that a particular therapist doesn’t know how to do this triage.
The solution is simple (but not easy). There’s an old family therapy adage that states that therapy must include the person who wants change, the person who must change, and the person who can change. My addition to this bit of wisdom about who to bring into the sessions is that when all three people are the same person, you do individual therapy.
To elaborate a bit, the person who must change might be the person sent to therapy, but it might be someone in a system with the person sent to therapy who keeps the problematic pattern alive. This is what Wachtel (2014) calls a vicious circle and, by extension, a vicious accomplice. Behaviorally, if the relevant consequence of problematic behavior is the reaction of specific family members, family therapy is indicated.
Put differently, if the therapist and client’s life goals for the client are organized around one other person or one set of family members, couples therapy with the one other person or family therapy is called for. If the mutually agreed-on life goals are more extensive than an improved marriage, say, or a more functional home life, then individual therapy makes sense—but only as long as the client is living in a place that doesn’t necessitate relying on the problematic patterns.
Read More Here: 5 Ways Biodiversity Affects Mental Health: Nature’s Therapy!
When choosing a therapist, look for someone who doesn’t already know what’s wrong or how they can help. For more of my writings on psychology and therapy, visit my blog at michaelkarson.com
References
Nichols, T. (2017). The death of expertise: The campaign against established knowledge and why it matters. Oxford University Press.
Minuchin, S. (1974). Families and family therapy. Harvard University Press
Wachtel, P. L. (2014). Cyclical psychodynamics and the contextual self: The inner world, the intimate world, and the world of culture and society. Routledge.
Leave a Comment