Essay Grade

SOCW 6301: Week 10 Assignment Guidelines
Qualitative Article Review and Critique
In approximately 7-10 pages (including title page and references), address the
following questions.
Title
•
After reading the entire article, do you think the title adequately describes
the study? Does the title catch your attention? Please explain.
Abstract
• Does the abstract contain the recommended content (see “Abstract,”
pp. 210–211, in Yegidis et al.)? How difficult do you think it is to
summarize so much information in 150–250 words? Please explain.
Introduction
• Why did the authors conduct this study and write this article? What was the
problem of interest or concern? Be specific. Use quotes and paraphrases
with citations. What audience might be interested in this study?
•
Do you feel the problem is significant enough to warrant a journal article?
Did you have a “so what” reaction? If so, why do you think it was accepted
for publication? Please justify your position.
•
To what extent does the literature presented in the introduction help you
understand the problem? How does the literature reviewed put the problem
in context? Be specific.
•
Does the researcher indicate how this research is different from and/or
similar to earlier ones reported in the literature? Summarize what this
article intends to add to the knowledge base.
•
Do the authors state their research questions and/or hypotheses? What
are the hypotheses or focused research questions?
Methods
• What specific qualitative method is used? How does a qualitative research
design correspond with the research questions? Can you determine
whether the design was appropriate?
© 2016 Laureate Education, Inc.
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To what extent can the design answer the research questions?
Elaborate.
•
What were the key concepts being explored in the study? What measures or
observations were used in the research? Explain why you do, or do not, think
that the methods used to collect the data are described clearly enough to
allow for replication. Be specific and please elaborate.
•
How was research reactivity and bias managed in the study?
•
Explain whether or not information was provided concerning the credibility
and trustworthiness of the measures or observations. Was this information
adequate? Be specific.
•
What strategies were used to establish credibility?
•
Was there evidence of an audit trail and/or peer consultation on the project?
Sample
• How were the participants recruited or selected for the study? What sampling
strategy was used? Did the author(s) offer any justification for the sample
size? Are you satisfied with the information reported about the sample? What
questions might you have about the sample that were not addressed? Please
be sure to provide an explanation for all of your answers.
•
Are the demographics of the participants (e.g., background characteristics
such as age, race, etc.) described in sufficient detail? If so, how is the
presentation of this descriptive data useful in evaluating the research? If not,
please explain how that may affect the evaluation of the research.
•
Was the sample reflective of the population from which it was drawn? Is
representativeness important in this research? Please explain.
•
Please explain any ethical concerns you may have about the sample and how
the sample was recruited.
Results
• How were the data analyzed? (What qualitative data analysis technique
was used?)
•
How extensive or ‘thick’ were the descriptions supporting findings? Was
the context adequately described?
•
How did the researchers corroborate their findings? For example, were
triangulation, member checking, or thick descriptions used? If so,
© 2016 Laureate Education, Inc.
2
please explain how it was used. If not, explain what you would
recommend to corroborate the findings.
•
To what degree do you find the research procedures increased the
trustworthiness of the findings?
•
Explain how easy or difficult it was for you to understand the reporting of
results. What questions do you have after reading the results section? Please
elaborate.
•
Were the findings transferable, applicable or useful for your population,
setting or area of practice? What are the limits of transferability?
Do you feel the results of this study have meaning for social
work practitioners or managers? Please elaborate.
•
Discussion
• Explain whether or not the authors made sense of their data in the discussion
section. Explain why you think the conclusions are (or are not) reasonable.
•
•
Did the authors discuss the limitations of their study? Did they stay within
the limitations of their findings, or did they make more of their findings than
was warranted? Please elaborate.
Did the author(s) suggest issues that future research should consider? If
so, were there any surprises? Please elaborate.
© 2016 Laureate Education, Inc.
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JOURNAL OF FAMILY PSYCHOTHERAPY
2016, VOL. 27, NO. 2, 99–108
http://dx.doi.org/10.1080/08975353.2016.1169019
Combined Couples’ Therapy: A Qualitative Study of
Individual and Conjoint Sessions
Anisha Shah, Ashmeet Nagpal, Manjula V., and Ila Lyngksiar Rynjah
Department of Clinical Psychology, National Institute of Mental Health and Neurosciences,
Bengaluru, India
ABSTRACT
KEYWORDS
Combined couples’ therapy is an integrative format of couple
therapy where the therapist combines the use of individual
and conjoint sessions in therapy. However, little is known
about the processes that occur in this type of therapy. In this
study, a qualitative analysis of written records was undertaken
to identify certain characteristics of combined couples’ therapy
themes and goals. There were 15 cases identified for inclusion
in this study. The majority of the clients were young educated
couples in their first family life cycle stage, from middle to
upper socioeconomic status, having dual careers. Results
show that while dyadic/systemic issues are discussed in individual and conjoint sessions, the sessions differ in goals
addressed. Moreover, certain themes like self-in-marriage concerns, unresolved past conflicts, violence, and resistance for
conjoint sessions are addressed exclusively in individual sessions. The findings have implications for individual and conjoint sessions in couples’ therapy.
Conjoint sessions; couple
therapy; goals; India;
individual sessions; themes
Introduction
Over the last few decades, couple therapy has become increasingly prominent in mental health services. Research on couple therapy has recognized
the controversy around individual sessions versus conjoint sessions since
1980s. The long-standing debate of type of sessions to be offered has found
one possible answer for many couple therapists. This involves using the
format of combined couples’ therapy (CCT) where therapists use individual
sessions as well as conjoint sessions to achieve resolution of presenting
relationship problems. While this appears like a reasonable solution, it still
leaves the therapist with various dilemmas about content of individual/
conjoint sessions. Further, the nature of presenting problems often necessitates the use of individual sessions. The question of whether the use of
individual sessions will benefit the client but harm the relationship troubles
the therapist at every stage. In their review article, Snyder, Castellani, and
Whisman (2006, p. 339) have also pointed out clearly that therapists need
CONTACT Anisha Shah
anishah1961@gmail.com
Department of Clinical Psychology, National Institute of
Mental Health and Neurosciences, Hosur Road, Bengaluru 560029, India.
© 2016 Taylor & Francis Group, LLC
100
A. SHAH ET AL.
competency “…in recognizing and treating the recursive influences of
individual and relationship difficulties.” Therapists require more insights
from research on processes in individual as well as conjoint sessions in
order to develop the desired competency. Gurman (2011) emphasized the
need to bridge the research-practice gap in couple therapy through research
that is practice driven and rooted in clinician’s experience. In this study, we
examine session records of couples who received CCT in order to identify
patterns in themes and goals across individual and conjoint sessions. This is
a retrospective qualitative study of CCT as it naturally occurred in a service
center. Open-ended data of written records of cases who received CCT were
analyzed by Shah, Nagpal & Manjula to discover new knowledge for training and practice of psychotherapies.
Method
Data sources and setting
Criteria for selecting case records
For this study, typical case sampling (Patton, 1990) was used and case records that
fulfilled the following two criteria were identified: (1) couples who had a minimum of 3 and a maximum of 10 sessions, and (2) couples for whom at least one
individual session was held with either spouse by the couple therapist. Sample
records were selected from the target population of married persons seeking help
from a marital enrichment clinic. A total of 15 case records were identified. The
case records consisted of written records of each session. Therapists are trained in
maintaining hand-written session notes in their basic psychotherapy training.
They maintain summaries of each session that cover client details, experiences,
themes, goals, clarifications, interventions, and observations/concerns. A total of
86 pages of records were analyzed in this study.
Five therapists and one supervisor were involved in these cases. All are
with clinical experience of 2–30 years and provide therapy and supervision,
in addition to conducting workshops in marital and family therapy at a
mental health institute in southern India. All the authors form the core
team that provides Marital Enrichment Services (MES) and conducts workshops for professionals as well as consumers.
Therapy Setting
The primary source of data is the MES clinic at a center for well-being located in
a residential area of Bengaluru. The clinic offers brief therapy to couples
experiencing mild to moderate marital distress. The marital enrichment model
used is based on the core principle of identifying and utilizing strengths and
available resources in the partner(s) to address presenting problems from first
session itself. Gurman (2003) has also emphasized the balanced awareness of
JOURNAL OF FAMILY PSYCHOTHERAPY
101
strengths and weaknesses and de-emphasis on centrality of treatment in client
(s)’ lives as only this can make brief therapies possible. The timing of first contact
and subsequent frequency of sessions is an artifact of many features like availability of information, encouragement by friends/family to take help, problems
of daily living, work, and career demands involving travel. Enrichment and
Systemic Individual Marital Therapy (SIMT) principles (Shah &
Sathyanarayana, 2011) are kept in the forefront by the therapists.
Appointments are largely regulated by the clients. The model was examined
initially through a research study on efficacy of marital enrichment program for
younger couples (Pothan, 2008) and was subsequently refined through therapy
with a variety of clients at the well-being center. However, in this format, the
choice of coming alone or with the partner remains with the client(s).
Ethical issues followed during this research were that identifying data of
clients was kept confidential by the coders, Shah ensured that the process of
coding did not affect clinical services if there were ongoing appointments for
the cases, and the records were accessed by the team providing services hence
client privacy was not invaded.
Data extraction and analysis
Thematic analysis of case records and descriptive analysis of sociodemographic and therapy variables was done.
Qualitative content analysis was used to identify emergent themes from the
case records. Qualitative content analysis is a widely used method for extraction
of themes/codes from textual data or documents (Joffe & Yardley, 2004;
Krippendorff, 2004; Ryan & Bernard, 2000). Given the exploratory nature of
the research, an inductive approach to content analysis (Elo & Kyngas, 2008) was
adopted. Nagpal created a data extraction matrix in Microsoft Excel
(Papadopoulos et al., 2012) with the headings: session themes and goals. Each
case record was then read session by session and each theme/code extracted was
listed under the appropriate heading for each client. The themes were then
grouped under higher order categories that were created based on existing
couple and family therapy literature. For each theme, the serial number of the
case record in which the theme was present was noted. For verification of
themes, Manjula independently read each case record session by session and
noted her concurrence or divergence for the presence or absence of each theme
extracted by the second author. She also independently extracted additional
themes wherever necessary. Themes were revised until consensus was reached.
Percentage of consensus between Nagpal and Manjula was 93.3%. Nagpal and
Manjula reviewed disagreements and arrived at a consensus for each case. This
stage involved going back to the raw data (session notes of case records) to
compare interpretations of session notes by the two authors.
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A. SHAH ET AL.
Results
The 15 couples who received CCT were in the age range of 21–42 years,
married for an average of over 2 years but the duration varied from 3
months to 8 years. Average age of husbands was 32.66 years and that of
wives was 26 years. Eighty percent of the couples were in the first family life
cycle stage of couples without children (N = 12), about 13% had children
with oldest child less than 6 years (N = 2) and one couple with oldest child
2 ½ years.
Total number of sessions that these 15 couples received was 85. In this,
there were 43 conjoint sessions, 17 individual sessions with husbands, and 20
individual sessions with wives. Both the husbands as well as the wives had an
average of 1.33 individual sessions indicating that gender perhaps does not
play any role in individual sessions. Average of 2.86 conjoint sessions had
occurred for this group. The range of individual sessions was 0–3 for husbands and 0–5 for wives, whereas the range for conjoint sessions was 1–8.
This suggests that in CCT, balancing individual sessions for husband and
wife may not be necessary in the first phase of therapy.
CCT codes for individual/conjoint sessions
The following section shows the results from the analysis of 43 conjoint
sessions and 37 individual sessions.
Session themes
The categories for organizing session themes originated from Shah (1996)
and couples’ therapy training and supervision being practiced in a family
therapy services center for nearly 20 years.
Table 1 shows that the following themes are discussed in individual and
conjoint sessions: emotional aspects of dysfunctional communication and
role functioning (dyadic domain), personality issues of spouse, work/career
(individual experience), family of origin issues, wife’s financial independence,
decision-making difficulties (systemic experiences—family), separation/
divorce, expectations, and ideologies (systemic experiences—social system).
This indicates that dyadic/systemic issues are also discussed in individual
sessions, while conjoint sessions may sometimes focus on individual issues
with a spouse.
Themes present only in individual sessions are: self-in-marriage issues,
personality issues in self/unresolved conflicts, victim stance, resistance for
conjoint sessions (individual experience), violence, supra-system involvement
(systemic experiences—social system). These are issues that a married individual may find difficult to bring up in a conjoint session.
JOURNAL OF FAMILY PSYCHOTHERAPY
103
Table 1. Themes in individual/conjoint sessions.
Therapy/session themes
Themes related to dyadic/relationship experience
Physical intimacy issues
Emotional reactivity/anger outbursts arising from dysfunctional
communication patterns
Issues regarding role functioning
Prescription of rituals
Individual sessions Conjoint sessions
(freq)
(freq)
5
4
9
5
2
0
1
1
Themes related to self/partner individual experience
Personality issues of spouse
Personality issues in self/unresolved conflicts
Issues related to psychopathology in spouse
Issues related to psychopathology in self
Victim stance
Self-in-marriage issues
Issues related to work/career
Resistance for conjoint sessions
5
3
2
4
2
3
1
2
6
0
7
1
0
0
2
0
Themes related to systemic experience—family
Family of origin issues
Parenting issues
Financial independence of wife
Difficulties in decision making
7
0
2
1
6
2
1
1
Themes related to systemic experience—social system
Separation/divorce issues
Different expectations in marriage/differences in ideology
Violence/supra-system involvement (neighborhood, police)
5
4
1
5
4
0
Certain issues like parenting issues and family rituals from dyadic domain
and systemic experiences—family are likely to be absent from individual
session processes but evident in conjoint session processes. As these issues
are closely linked with mutual decision making processes in the family, it is
probable that they are more likely to come up in conjoint rather than
individual sessions.
Seven couples (46.7%) had the following themes that were discussed in
individual as well as conjoint sessions. These themes are:
●
●
●
●
●
●
●
●
physical intimacy issues
emotional reactivity/anger outbursts arising from dysfunctional communication patterns
personality issues of spouse
issues related to psychopathology in spouse
family of origin issues
financial independence of wife
separation/divorce issues
different expectations in marriage/differences in ideology
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A. SHAH ET AL.
Hence, we conclude that perhaps therapists must have competence to
address these themes in either type of sessions and also be able to preserve
continuity on these themes through the changing structure of sessions.
Therapy goals
Dyadic, individual and generic therapy goals were coded separately.
Results (Table 2) show that improving communication/interaction pattern
is most frequently evident in conjoint sessions, whereas ventilation and
empowerment in dyad is evident in individual sessions. In five couples
(33%), it appears that the generic goal of ventilation is more prominent in
individual sessions, whereas concerns about engagement in therapy are more
critical in conjoint sessions, though these goals are equally important across
sessions.
Discussion
The results show that certain dyadic themes were equally prevalent in both
individual and conjoint sessions. Married distressed clients are likely to be
preoccupied with dysfunctional communication, intimacy, and role functioning. Hence, training needs to facilitate appropriate skills in therapists for
their application in any type of session. Systemic themes included family of
origin issues, wife’s financial independence, decision-making difficulties,
separation/divorce related concerns, and differences in expectations/ideologies. This is culturally pertinent as families in India continue to influence the
couple for a long period and the hierarchy of family of origin, as well as
gender/power inequalities considerably influence couple choices.
It was interesting to note that individual themes were also discussed in
conjoint sessions, for example, concerns about spouse, and/or work/career
Table 2. Goals in individual/conjoint sessions.
Goals
Dyadic goals
Improve communication/interaction pattern
Improve physical intimacy
De-escalate conflict/improve conflict resolution skills
Individual goals
Empower individual(s) in the dyad
Promote self-care in individual in the dyad
Alleviate symptoms of depression
Ventilation
Prepare for conjoint sessions
Generic therapy goals
Engagement/keep couple connected with therapy
process
Engage absent spouse in therapy process
Individual sessions
(freq)
Conjoint sessions
(freq)
1
0
1
12
2
3
5
2
1
8
3
2
0
0
2
0
4
7
5
0
JOURNAL OF FAMILY PSYCHOTHERAPY
105
related issues. Personality issues/psychopathology in the spouse can often be
the main presenting complaint in married clients. We find that partners are
often more comfortable in conjoint sessions to discuss personal issues as it
decreases focus on self and subsequently encourages the partner to address
these when comfortable.
Decisions concerning individual sessions are also not solely driven by the
need to focus on self, as perhaps theoretically expected, but also due to need to
focus on partner, non-availability of partner for conjoint session, and/or due to
challenging interactional dynamics in conjoint sessions. Themes such as
exploration of unresolved intra-psychic conflict, resistance to conjoint work,
victim stance, and self-in-marriage concerns occurred exclusively in individual
sessions. Thus, therapists may need to address these issues initially for more
useful conjoint work later on. In addition to these, violence in relationships and
subsequent involvement of the supra-system is another theme that emerged
exclusively in individual sessions. However, violence is not often seen to be a
presenting complaint, rather it emerges as a maladaptive mechanism to address
relationship conflicts. Couples also hesitate to talk about violence spontaneously
in an attempt to preserve the relationship. Therapists’ sensitivity to these issues is
essential when multiple minor issues are coexisting in marital difficulties.
Therapists also need to be aware that relevant themes that can spontaneously
emerge in individual sessions may be missed with an insistence on joint sessions.
Therapy goals were seen to be clearly differentiated in individual and
conjoint sessions. Predictably, dyadic goals were addressed more often in
conjoint sessions, while individual goals were addressed more often in
individual sessions where ventilation and empowerment were most prominent. These sessions can provide a safe space for married individuals to
express relationship distress without fear of adverse reactions from the
partner, or fear of hurting the partner. Other exclusive goals of individual
sessions were symptom reduction and focus on self-care which are a part of
any person’s right to mental health care irrespective of relationship outcomes. Preventing drop-out from service is also easier when they select the
type of session in each appointment.
The goal of improving physical relationship was seen exclusively in conjoint sessions, even though themes related to physical intimacy were present
in individual sessions as well. This affirms that clients hold an interactional
perspective of intimacy and intervention needs to be oriented accordingly.
Psychological theories that view intimacy as a personality issue are less useful
for clients than relationship based approaches to intimacy.
Findings from this study suggest that the individual sessions experience in
CCT may be similar to the individual systemic marital therapy experience as
indicated by presence of both dyadic and systemic themes in individual
sessions (Heitler, 2001; Shah & Satyanarayana, 2011). LaTaillade, Epstein,
and Werlinich (2006) and Stith, McCollum, Amanor-Boadu, and Smith
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A. SHAH ET AL.
(2012) have also found that identification and initial assessment of violence
usually occurs and should be addressed in individual sessions even if subsequent treatment is conjoint. Hence, use of individual sessions to address these
themes in CCT can be very useful. Inequalities in the relationship also necessitate the need to empower one member of a couple through individual
sessions. Therapists’ actions that can facilitate power balance such as “creating
a space for the one-down voice” and “validating competence of the one-down
person” (Ward & Knudson-Martin, 2012) can be used in individual sessions,
especially when the spouse feels vulnerable or the partner is unavailable.
Improving communication and conflict resolution skills are common components of most Marital Enrichment Programs that show high satisfaction rates
(Kaiser, Hahlweg, Fehm-Wolfsdorf, & Groth, 1998; Thuen & Lærum, 2005) and
the same have emerged as important goals in the present study with 53% of
conjoint sessions targeting these goals.
Clinical implications
Therapists in developing countries like India perhaps can expect mild–moderate
marital discord couples to require at least three conjoint sessions, more than one
individual session, and individual sessions to be scheduled as per the need of the
husband/wife—within the first 10 sessions. Competence to manage dyadic/
systemic/self-in-marriage themes in individual as well as in conjoint sessions is
likely to be one of the core skills required in CCT. Moreover, apart from the
focus on individual needs, individual sessions can often cover systemic as well as
dyadic themes/goals (power imbalance, preparation for conjoint sessions) and
perhaps therapists all over the world can use this knowledge while working with
married persons in individual sessions.
From a cultural perspective, it was observed that given the urban setting of the
clinic, apart from linguistic diversity and nature of family of origin dynamics
post marriage (such as prolonged dependency and need to preserve relationships), many of the usual challenges that therapists in India are trained to face
such as rural–urban differences or specific regional diversities (Shah et al., 2000)
were not encountered in the present study. Yet therapist may need to remain
alert to these aspects in help-seeking population. Disparate availability of services across rural–urban areas and globalization effect on psychotherapy needs
encourages people to travel long distances/seek help in cities of their choices
rather than where they live. Therapy with young, educated, dual-career couples
from middle to upper middle socioeconomic status, and in early family life cycle
stages is likely to correspond with themes and goals identified here. The study
group formed about 14% of the clients seen in the MES. Hence, though CCT
may not be the dominant need of married persons, some could perhaps dropout if not offered this format of therapy.
JOURNAL OF FAMILY PSYCHOTHERAPY
107
Limitations of qualitative research and future directions
It is advisable to approach qualitative data analysis done in this study with
certain cautions. Unlike quantitative designs, it is hard to have large sample
sizes, randomization in the process of selection of participants, and wide generalizability of results. Further, qualitative designs usually do not explain cause
and effect—the factors that caused individual sessions versus conjoint sessions to
occur could not be determined in this research. Longitudinal studies may be
designed to predict type of sessions based on themes and goals (individual/
conjoint) as well as to help discover specific intermediate outcomes (individual/
dyadic/systemic) with the format of CCT. Finally, though bias was minimized
during analysis through consensus on coding, authors’ multiple roles as therapist/researcher/coder made it impossible to have a data collection plan that
searches for contradictory data. Future research may be based on quantitative
designs that can reduce subjectivity by using observational data of sessions
(audio/video recording) and independent therapists/researcher/coder (where
resources are available, like in the developed countries). In developing countries
where a large number of married individuals/couples are seen for counseling
and psychotherapy services, a checklist of themes and goals discovered in this
research can be useful for decision making about individual and conjoint
sessions.
Conclusions
Overall, we conclude that CCT is not merely a combination of individual
and conjoint sessions. Rather it is a true integration since themes and
goals in both formats are interlinked and complementary. It facilitates the
resolution of interpersonal as well as intrapersonal objectives that affect
couples. Further process research on couple experiences on helpful aspects
of individual and conjoint sessions can generate more comprehensive
knowledge on CCT that can facilitate good practice as well as training in
marital and family therapy.
Acknowledgements
The authors would like to acknowledge Ms. Madhurini Vallikad (Junior Consultant, Marital
Enrichment Services) and Ms. Padmavathy and Ms. Anurupa (staff) NIMHANS Centre for
Well-Being, for their contributions.
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