Examining Experiential and Humanistic Theories For this Discussion, you will review experiential and humanistic theories presented this week and you will consider the questions posed abov

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The American Journal of Family Therapy

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Using Symbolic-Experiential Family Therapy to Treat Adjustment Disorder: A Case Study

Melissa L. Bauman & Christopher K. Belous

To cite this article: Melissa L. Bauman & Christopher K. Belous (2016) Using Symbolic- Experiential Family Therapy to Treat Adjustment Disorder: A Case Study, The American Journal of Family Therapy, 44:5, 285-300, DOI: 10.1080/01926187.2016.1231599

To link to this article: https://doi.org/10.1080/01926187.2016.1231599

Published online: 04 Oct 2016.

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Using Symbolic-Experiential Family Therapy to Treat Adjustment Disorder: A Case Study

Melissa L. Bauman and Christopher K. Belous

Master of Family Therapy Program, Mercer University, Atlanta, Georgia, USA

ABSTRACT Despite studies claiming Adjustment Disorders (AD) affect up to 10% of the general population, research is severely lacking for effective treatment recommendations and screening tools. This article presents the treatment of a 30-year old Caucasian male diagnosed with AD – mixed anxiety and depression subtype. After 12 standard 60-minute sessions, treatment using a Symbolic-Experiential Family Therapy (SEFT) approach resulted in the alleviation of depression and anxiety symptoms. This case study provides preliminary evidence for the effectiveness of SEFT using a mixed methods case study. Implications for further study, and the usefulness of SEFT for the treatment of AD, is presented.

Research regarding Adjustment Disorder (AD) is sparse both in primary care and mental health settings despite a recent study by Ponizovsky and colleagues (2011) stating approximately 10% of the general population and up to 50% of patients in psychiatric hospitals meet the qualifications for this diagnosis. AD has been recog- nized as a disorder for decades, but severely lacks epidemiological research (Casey & Doherty, 2012). Patria Casey (2014) hypothesizes that the lack of research may be attributed to the subjective interpretation of “normal” stress reactions, the lack of specific diagnostic symptom criteria, and the overlap of criteria indicating adjustment disorders, major depressive disorder and generalized anxiety disorder. AD experts urge for an increase of studies regarding adjustment disorders after finding rates of suicidal ideation almost identical to those of patients with major depressive disorder, between 10% and 48% (Casey et al., 2015; Chung et al., 2014). Others stress that the lack of a standardized assessment instrument is to blame for the deficit in research (Strain & Friedman, 2011).

Adjustment Disorder is one of the most common working diagnoses in mental health settings and 7th most popular diagnostic category in psychiatric inpatient settings (Glaesmer et al., 2015). According to The Diagnostic and Statistical

CONTACT Christopher K. Belous [email protected] Mercer Family Therapy Center, Atlanta, 105 Collier Road, Suite 4040, Atlanta, GA 30309. © 2016 Taylor & Francis

THE AMERICAN JOURNAL OF FAMILY THERAPY 2016, VOL. 44, NO. 5, 285–300 http://dx.doi.org/10.1080/01926187.2016.1231599

Manual (DSM-5; American Psychiatric Association, 2013), AD requires the devel- opment of emotional or behavioral symptoms in response to an identifiable psy- chosocial stressor, either chronic or acute, within three months of the onset of the stressor. The symptoms must be clinically significant and represent distress out of proportion to the severity or intensity of the stressor causing significant impairment in social, occupational, or other areas of functioning (Strain & Fried- man, 2011). The symptoms must not meet criteria for any other disorder or indi- cate normal bereavement, and must not persist for longer than six months after the termination of the stressor. AD may present with symptoms of depression, anxiety and impulse control (Pelkonen, 2005; Glaesmer, Romppel, Br€ahler, Hinz, & Maercker, 2015).

Concerns and advances in diagnosing Adjustment Disorder

Due to the growing usage of the AD diagnosis, there has been recent peaked interest in the topic, thus shining light on the severity of deficit in research. With the overlap of symptoms – and lack of specific diagnostic criteria—AD is often misdiagnosed as Major Depressive Disorder (MDD) or Generalized Anxi- ety Disorder (GAD) and treated as such, adding to the difficulty of studying the disorder. Casey and Doherty (2012), conducted a study they believe illustrates the trend of misdiagnosis. Rates of AD declined from 28% to 14% between 1988 and 1997 while diagnoses of MDD rose from 6.4% to 14.7% over the same period. One characteristic of AD helping clinicians to distinguish it from MDD is that the removal of the client from the stressor or stressful situation will result in a reduction of symptoms that would otherwise persist from MDD (Casey & Doherty, 2013).

Strain and Friedman (2011) state that the non-specificity of diagnostic criteria has also hindered the development of assessment instruments. Because symptoms of AD are often open to subjective interpretation, critics pose that the only distinc- tion between AD and ordinary life problems may be that the diagnosis itself implies the severity of the disturbance is sufficient to justify clinical attention or treatment (Carta, Balestrieri, Murru, & Hardoy, 2009).

Most widely utilized structured interview tools fail to include AD. Until 2014 there were no questionnaire type instruments in existence for the screening or diagnosis of AD. Clinicians commonly diagnose the disorder utilizing unstructured interviews and client descriptions of symptoms. Because symptomology commonly mimics MDD, GAD or impulse control disorders, clinicians may assess symptoms utilizing questionnaires for such disorders (Carta et al., 2009).

Treatment

Research has shown prognosis for patients with AD is good, but because of the lack of research regarding treatment, recommendations are limited (Srivastava, Taluk- dar, & Lahan, 2011). Most research regarding the treatment of AD has focused on

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the use of pharmacology to relieve depressive and anxious symptoms. Although research suggests that psychotherapy is the treatment of choice for AD, little research has focused on the efficacy of specific psychotherapy approaches. Critics often undermine the necessity of treatment due to the brevity of symptoms despite evidence that AD is associated with suicide risk and may result in severe symptoms impacting functioning (Casey & Doherty, 2013). A five-year follow-up study dem- onstrated that 71% of participants no longer met criteria for any mental disorder after the treatment of AD with psychotherapy in general (Carta, 2009). Other researchers have documented successful symptom reduction utilizing a combina- tion of medication and psychotherapy (Sundquist et al., 2015).

Symbolic-Experiential Family Therapy

Symbolic-Experiential Family Therapy (SEFT) was developed by Carl Whitaker and is a growth-oriented psychotherapy approach that is not based on intellectual logic, but rather on interactive processes, metaphorical language and personal interaction (Mitten & Connell, 2004). SEFT proposes that the facts of life are unchangeable, but a person’s attitude or feelings can be altered to produce a more positive response to stressful situations. Kaye and his colleagues (1986) argue that people are not motivated to change unless they are pushed into a crisis state as a result of interrupting dysfunctional patterns through heightened awareness and emotion. One goal for experiential therapists is to help the client re-interpret the current dilemma to reveal the positive function for their dysfunction and leave with a vision of immediate possibilities for change (Napier, 1987; Mitten & Con- nell, 2004).

Because some populations may have an underlying predisposition to stress- related disorders, SEFT may be effective in the treatment of AD due to learned maladaptive coping strategies challenged by the therapist in session. Research by Smith (1998) may indicate SEFT as a useful treatment for AD with anxiety because the increasing of anxiety during session allows clients to adapt new coping mecha- nisms to combat further symptoms. Kaye (1986) summarized the well-balanced role of the SEFT therapist as a coach, a Zen master, a combatant in war and a sur- rogate grandfather.

SEFT therapists connect with clients through the use of humor and self-disclo- sure. Whitaker argued that success of SEFT relied heavily on the true self of the therapist and a heavy emphasis of personal intuition (Smith, 1998). Whitaker coined SEFT as the “therapy of the absurd” because of his use of playfulness with families meant to shake up the system and interrupt dysfunctional cycles, thus inducing change. His positive therapeutic relationship with clients allowed him the ability to use paradox and absurd statements to illuminate dysfunction in the sys- tem. Myriads of research has indicated the most important factor indicating suc- cess in therapy is the development and maintenance of an open, trusting, and collaborative therapeutic relationship (Rait, 2000). In fact, Lambert’s common

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factors model attributes 30% of client change to the development of a therapeutic relationship (Lambert, 2006). SEFT proposes that the process of therapy, after the development of a therapeutic alliance, becomes a mutually shared experience of inevitable change on the part of the therapist and the client (Kaye et al., 1986).

To date there is very little empirical research on SEFT. Critics of the theory argue that the techniques utilized in symbolic-experiential therapy are too subjec- tive to objectively measure and call for the creation of manualized training. How- ever, SEFT experts declare that developing such treatment protocol may interfere with the therapy itself (Mitten & Connell, 2004).

Change mechanisms

The goal of SEFT is to provide experiences for the client that will reshape dysfunc- tional symbols and interactions resulting in positive, lasting change (Mitten & Connell, 2004). Experts in SEFT identified emotion as the primary element in the therapeutic process. Emotional expression promotes maturation, opportunities for ongoing growth and serves as a historical point of reference and context through which a “corrective emotional experience” occurs (Suarez Pace & Sandberg, 2012).

According to Mitten & Connell (2004), Symbolic-Experiential Family Therapy follows six core values or goals:

1. Generating an interpersonal set through the expansion of the symptom and introspection by each member of the system regarding their contribution to the problem and maintenance of dysfunctional processes.

2. Creation of a suprasystem through the therapist’s successful joining of the family system. The therapist creates a therapeutic relationship with each member of the system through utilization of self-disclosure to present alter- nate perspectives to the problem.

3. Simulating the symbolic context to allow for symbolic experiences to occur in session. The therapist shifts from reality-based to symbolic listening allowing the creation and understanding of client’s meaning of the problem.

4. Activation of stress within the system by increasing emotional intensity in the therapy room. Whitaker believed anxiety fostered growth and clients would not be motivated to change in the absence of such discomfort. Increase in emotional intensity combats therapeutic impasse from systems not desperate enough to change.

5. Symbolic experiences are created during interactions in therapy that are beyond the client or therapist’s scope of conscious awareness. If meaningful change is to be maintained after therapy, a symbolic experience must be cre- ated and assigned meaning.

6. Therapists move out of the system through distancing once termination is imminent. Therapy is an experience of mutual growth and the therapist should acknowledge self-growth as a result of working with a client.

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Therapeutic intervention

Although SEFT does not adhere to manualized treatment protocol, the approach does include the use of specific therapeutic intervention techniques. These techni- ques, proposed by Carl Whitaker are viewed as an extension of the self of the therapist and continually contribute to the genuineness of the therapeutic rela- tionship. SEFT theorists stress that intervention techniques should not be univer- sally applied to every case in the same manner as this could detract from the “here and now” of the therapy experience. Whitaker believed that interventions ought to be spontaneous rather than pre-planned to aide in the authentic flow of the session. When techniques are properly implemented in the presence of a healthy therapeutic relationship, they can determine the difference between “good” or merely “adequate” therapy (Connell & Russell, 1987).

Confrontation

Symbolic-Experiential Family Therapy utilizes confrontation to point out, and interrupt dysfunctional patterns and interactions. SEFT stresses genuine caring for clients is critical to the success of therapy. However, confrontation is viewed as a necessity in the process. It is out of care for clients that confrontation is used to jolt the system out of homeostasis resulting in the consideration of alternate patterns of interaction (Mitten & Piercy, 1993). Confrontation may provide clients with the opportunity to share non-verbal cues regarding unspoken feelings. Use of confron- tation implies the message that the system’s dysfunctions are visible and require immediate attention. Through confrontation the therapist takes the lead and pres- sures the client to make changes in dysfunctions (Connell & Russell, 1987).

Metaphors

Many of the recognized major family therapy theories involve the implementation of metaphors to help clients visualize or express ideas, emotions and concepts that cannot be said more clearly. They may also be utilized for decorative effect in ses- sion, and have the power to define reality. Metaphors embrace a postmodern approach in which multiple truths can coexist without one having privilege over another (Davies, 2013).

Use of self

Self-disclosure is a hallmark of SEFT. Therapists use their own experiences with the client in the room as the ‘heart of therapy’ (Rober, 2011). Symbolic-Experien- tial therapists utilize self-disclosure to create a healthy, genuine therapeutic rela- tionship. Critics of the approach stress that SEFT utilizes an amount of self- disclosure and ‘realism’ that would be unacceptable with other theories. Encoun- ters with clients cannot help but induce strong feelings in the therapist. Therapy without such involvement would not produce authenticity and growth, but it also

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creates complex challenges for the therapist in every session. Genuine self of the therapist is employed to appropriately handle such intense feelings toward the sys- tem (Rait, 2000).

Methods

There is a lack of published research on the treatment of adjustment disorder as a diagnosis—more specifically on treatment with Symbolic-Experiential therapy. A case study is presented to explore the efficacy of one person’s successful comple- tion of therapy after diagnosis of adjustment disorder. The client’s name and sig- nificant identifying characteristics have been altered in order to protect their confidentiality.

Case presentation

Stephan, a 30-year-old Caucasian male contacted a student clinic for therapy to treat his recent onset of depressive and anxious symptoms after a divorce, stressful promotion at work, and the recent cancer diagnosis of a close family member. Ste- phan was raised in a small, conservative town in Northern Alabama and was the youngest of four children. His mother, father and three siblings were all successful lawyers and insisted Stephan follow family tradition. Stephan had close relation- ships with his mother and siblings, but a distant relationship with his father who left their family when Stephan was ten.

Stephan sought therapy after his wife of 18 months had divorced him approxi- mately three months prior. She informed Stephan that she was bisexual and wanted to pursue dating women. They maintained very limited contact. Stephan had a complicated and unsuccessful history with past intimate relationships. Shortly after the divorce, Stephan’s brother was diagnosed with stage 3 prostate cancer. Stephan moved in with his brother and assumed the role of primary care- giver; transporting him to doctor and chemotherapy appointments, cooking meals and contributing financially. In addition, Stephan was recently promoted at work, which came with many new responsibilities and stress. The recent promotion, accompanied by an increased workload and stress, occurred only weeks after assuming caregiver responsibilities and the leaving of his spouse.

Case study design

A single-holistic case study design was implemented to determine the efficacy of the approach for this one specific case; and to determine where and how interven- tions were useful for the client. For analysis, a Sequential Exploratory Mixed Meth- ods design was used; privileging the quantitative and qualitative data equally. To determine a baseline for symptom severity, and application of a proper diagnosis, Stephan completed a variety of self-report measures. All sessions were video recorded, allowing the therapist to analyze each session and document observable

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changes and responses to therapeutic interventions. It was determined that data collection would occur over the entire course of treatment, with no specified end dates – to allow for the natural progression of the case and to coincide with the the- oretical underpinnings of the Symbolic-Experiential approach to treatment.

Screening tools and questionnaires

As previously discussed in the literature review there is currently a shortage of diagnostic screening tools in existence for use specifically for AD. Client diagnosis in this study was completed utilizing a variety of instruments to assess depressive and anxious symptoms along with client self-report.

OQ-45.2 (Outcome Questionnaire) Created in 1996 by Lambert and his colleagues (Lambert, 2012), The OQ-45.2 is a 45-item self-report scale used to measure symptomatic distress in adult clients. The items address anxiety, depression, interpersonal interactions, and social role. The scale is designed to track client progress over time and to help clinicians better understand which areas of functioning are more problematic. The questionnaire has demonstrated high internal consistency and test-retest reliability with a Cron- bach’s Alpha of .84. Scoring ranges from 0 to 180 with scores of 63 or higher indi- cating clinical significance (Bringhurst et al., 2006).

Outcome Rating Scale (ORS) The ORS was developed as a brief alternative to the OQ-45.2 (Miller et al., 2003). The ORS features four subscales to assess client functioning in the areas of individ- ual, relational, social and overall well-being with scores ranging from 0 to 10 on each subscale. The ORS can be completed in less than one minute and is intended to track client progress over time. This scale is ideal to be completed prior to each therapy session. The measure has demonstrated high internal consistency and test- retest reliability with a Cronbach’s Alpha of .97 (Bringhurst et al., 2006).

Session Rating Scale (SRS) The SRS was developed to measure the health of the working therapeutic alliance, a long-standing predictor of successful therapy outcomes. The SRS, structured iden- tically to the ORS, is an ultra-brief self-report measure that can be completed in less than one minute at the end of each therapy session. The scale consists of four subscales including the therapeutic relationship—ensuring the client felt heard, understood and respected, goals and topics—ensuring the session was focused on client-centered goals, therapeutic approach and method—ensuring the therapist’s approach is a good fit for the client, and an overall client satisfaction score. Scores falling at 36 or below are cause for concern regarding the therapeutic relationship (Duncan et al., 2003).

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Generalized Anxiety Disorder-7 (GAD-7) The GAD-7 was developed as a short-form self-administered questionnaire version of the anxiety scale in the clinician administered primary care evaluation of mental disorders (PRIME-MD). Its purpose is to screen and measure severity of anxiety symptoms present over the past two weeks with scores ranging from 0 to 21. The scale has demonstrated acceptable internal validity and test-retest reliability with a Cronbach’s Alpha score of .89 (Spitzer, Kroenke, Williams, & Lowe, 2006).

Patient Health Questionnaire-9 (PHQ-9) The PHQ-9 is half the length of most other depression scales and can be completed in less than five minutes, but has comparable sensitivity and consists of the nine depression diagnosis criteria specified by the DSM-V. Upon completion, the scale is able to provide clinicians with evidence for a provisional diagnosis and rate symptom severity. The scale asks clients to answer the questions regarding depres- sive symptoms based on their experiences in the past two weeks and results in scores from 0 to 27, classifying symptoms from minimal to severe. The PHQ-9 has demonstrated acceptable internal validity (a of .89) and test-retest reliability (a of .84; Kroenke & Spitzer, 2002). In addition, the PHQ-9 has rapidly become one of the most frequently researched, translated, and used depression screening tool available (Moriarty, Res, Gilbody, McMillan, & Manea, 2015).

Client self-reports Research investigating the diagnosis of AD suggests that because there is no stan- dardized instrument in existence, client self-reports could be utilized to assist clini- cians in making a descriptive diagnosis through questions assessing symptom severity and impairment of functioning (Carta et al., 2009). Research suggests that client self-report of symptoms and severity be utilized in addition to more stan- dardized measures to enhance reliability.

Measuring change

Change will be measured through the comparison of client-completed measures from intake through termination. The scores from the OQ-45.2, ORS, SRS, PHQ- 9, and GAD-7 will be analyzed in addition to client self-reports regarding symptom severity and impairment to track improvement over time and response to thera- peutic intervention. Therapist will also document observable reductions in symp- tom severity and response to therapeutic interventions evident in session as further indication of change. In addition, sessions were recorded via video and audio in order to allow for the transcription, coding, and analysis of qualitative data. Qualitative data will be coded thematically and analyzed from a narrative analytical perspective, looking for specific instances of change identified by the cli- ent and therapist (Reissman, 2008).

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The goal of analysis is to determine whether or not the overall approach to treat- ment is helpful in alleviating symptoms of adjustment disorder through the applica- tion of Symbolic-Experiential therapy. Both quantitative and qualitative data will be used in conjunction to determine the efficacy of the approach, and to highlight suc- cessful interventions. If the client exhibits reduction of symptom severity and impairment through descriptive self-report and self-report measures, the client will begin biweekly sessions and move toward termination. The termination of services will provide further evidence of change and positive improvement toward client goals.

Results and data analysis

Metaphors

Metaphors were utilized to help the client visualize and apply meaning to situa- tions, symptoms and experiences that were otherwise difficult to comprehend or verbalize.

“The river” The river is a metaphor utilized in session to help Stephan visualize how his dis- comfort with expressing emotion frequently allows him to become overpowered by them. Stephan was asked to visualize his emotion as a river and picture himself standing on the bank far away from the water. He named the riverbank ‘logic’ and viewed it as his comfort zone. Stephan’s goal was to become comfortable enough with emotion that he could stick his toes in the water without increasing anxiety. Stephan professed that he felt if he “touched the water he would be swept away by it” because of his lack of experience around water. Stephan’s dysfunctional pattern of emotional avoidance was a difficult subject for discussion, but the utilization of the river metaphor allowed him to discuss the topic more openly.

“The tripod” Therapy with Stephan often referred back to the metaphor of a tripod. As he described the reasons for initiating therapy (job stress, divorce, cancer diagnosis) I began to visualize a tripod with three legs that depended equally on each other for stability; if one leg were removed the tripod would fall. The same appeared to be true for Stephan. When he made prior attempts to manage stress at work to reduce symptomology, the anxiety and depression manifested further in the other two areas. Stephan responded well to the use of the metaphor as evidenced by self- reports. Stephan came to the conclusion that although he could better manage work stress, and care for his ill brother and maintain a close relationship, he felt helpless against his feelings of loneliness and depression resulting from the divorce. He reported, “I feel like the cancer and the job stress are things I can’t really control, but I do have control over my love life, so I beat myself up over it.” However, Ste- phan reported the metaphor of the tripod provided a positive visualization of the distribution of stress and symptomatology.

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Stephan’s response to the use

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