REFLECTIONS ON THE ART & PRACTICE OF PSYCHOTHERAPY: Part II

Mickey Skidmore, AMHSW, ACSW, MACSW

In last month’s “perspective” I offered some reflections on the art and practice of psychotherapy by emphasising some contrasting observations between the psychodynamic and behavioural paradigms. This month I offer a few additional observations encompassing the art and practice of psychotherapy highlighting the unique nuances of family therapy approaches.

In the 1950’s eating disorder’s cases were largely stumping psychotherapists attempting individual treatment interventions. It wasn’t until family therapist’s began exploring eating disorders from a system’s perspective that we came to better realise the complexities of such conditions. However, even with an improved understanding of the complex dynamics associated with eating disorders, they remain to this day one of the most difficult and challenging conditions to successfully treat.

As a Clinical Social Worker I am naturally aligned with the strengths of a system’s approach. However, such approaches are not easily or readily embraced nor integrated well into a predominant medical model framework. In all my years of practice, I’ve never encountered an organisation that successfully or adequately manages the service delivery of family therapy from an administrative perspective. Most agencies organise around medical model principles. Thus, cases are opened on individuals (for documentation, record keeping and billing). Cases are not opened on “family systems.” Rather than open files for every individual participating in a family therapy session (which would quickly become quite cumbersome and chaotic, I’ve seen some organisations open a case on an “identified client” that is the primary focus of clinical attention within the family system.

In my lectures and tutorials I stress to my Social Work students that it is not sound nor appropriate clinical practice to engage in any form of theoretical approach or treatment model until a comprehensive (diagnostic) bio-psycho-social assessment has been completed. Only then can a range of methods or approaches be discussed, reviewed, considered and/or negotiated — including family therapy — which is a specific and intentional approach that emphasises more of a system’s view over a range of other linear approaches. For many organisations, the provision of family therapy is not aligned with these principles. In other words, I emphasise family therapy more as a specialty intervention rather that an initial assessment vehicle. 

The nuances of these issues become even more problematic for organisations without clear boundaries around service provision. It is ambiguous at best if you convey that you are not a child specialty service, yet you offer family therapy. It should not be surprising then, that parents will request family therapy predominantly as a work-around loop hole to secure (free) services for their child.

From a logistical point of view, private practice is the ideal arrangement for me to manage these challenges. However, it should be noted that in Australia, Medicare does not reimburse for family therapy. And most folks are looking for free services provided by the Government. Relationships Australia is one of the few such organisations and it often is limited in the funding they receive and have significant wait times for services. Head Space may also provided some limited form of family therapy if a young person is the focus of treatment and are generally recognised as more of a child specialty service. La Trobe University in Melbourne is also doing some interesting family therapy work at their Bouverie Centre.

I was initially trained in a family therapy approach involving a two-way mirror where the clinician engaged with the family while wearing a headset where they received suggestions, guidance and instructions from a family therapy team watching the session unfold on the other side. Being engaged in family therapy meant that you were being looked after by a team of highly trained mental health specialists. I am unaware of this approach being utilised or emphasised in Australia. The reality for many is difficult in navigating the cumbersome (administrative) procedures in organisations where parents are trying to work around obstacles or limitations imposed by agencies.

Just as there is considerable misinformation around the role of Social Work in Australia, it would be inaccurate to assume that family therapy is similar to or just like any other psychological approaches.