Designing and conducting treatment, domain 3

A 15-year-old is depressed and has passive suicidal thoughts. She says her parents "never listen," and family sessions show frequent criticism and withdrawal. The therapist wants an evidence-based family model that repairs the teen's trust in her parents. Which model BEST fits?

1. Attachment-based family therapy
   Attachment-based family therapy (Diamond) was built for depressed and suicidal adolescents and centers on repairing ruptures in trust between teen and parents.
2. Multidimensional family therapy
   Multidimensional family therapy was designed for adolescent substance use and delinquency, not for repairing a depressed teen's trust in her parents.
3. Multisystemic therapy
   Multisystemic therapy targets serious antisocial behavior through home, school and community interventions, not attachment repair in depression.
4. Family-based treatment (Maudsley)
   Family-based treatment (Maudsley) is the leading model for adolescent anorexia, with parents taking charge of refeeding.

Which outcome MOST distinguishes integrative behavioral couple therapy (IBCT) from traditional behavioral couple therapy?

1. Fewer arguments through problem-solving drills
   Problem-solving drills that reduce arguments are also traditional behavioral couple therapy; IBCT keeps them but is distinguished by acceptance.
2. A written quid pro quo behavior-exchange contract
   A quid pro quo behavior-exchange contract is a tool of traditional behavioral couple therapy, the model IBCT built on.
3. Greater mutual acceptance of each partner's differences
   IBCT (Jacobson and Christensen) adds acceptance work (empathic joining, unified detachment, tolerance building) to behavioral change, so greater acceptance of differences is its signature outcome.
4. Insight into each partner's family of origin
   Family-of-origin insight belongs to Bowen or psychodynamic couple work, not to either behavioral model.

Midway through couple therapy, the wife asks privately, “Honestly, should I just leave him?” What is the BEST response?

1. Advise her to stay together for the children's sake
   Advising her to stay for the children imposes the therapist's values on a choice that is hers.
2. Recommend a trial separation to clarify her feelings
   Recommending a trial separation steers a decision that AAMFT 1.7 leaves to the client.
3. Tell her that it is still too early to decide
   Declaring it too early to decide also makes the decision for her, just by delaying it.
4. Explore what she wants and the costs she foresees
   Decisions about staying or leaving belong to the client (AAMFT 1.7), so the therapist helps her clarify what she wants and the consequences she foresees.

A Bowen therapist builds a genogram with a couple who fight about money and learns that both of their fathers cut off their own brothers after inheritance disputes. How is the therapist MOST likely to use this finding?

1. To find exceptions when money talks went well
   Searching for exceptions when money talks went well is solution-focused technique, not multigenerational work.
2. To map current coalitions and plan an enactment
   Mapping current coalitions to plan an enactment is a structural use of family information, not the Bowen use of a genogram.
3. To assign a relational diagnosis to the couple
   A relational diagnosis labels the couple; the Bowen therapist uses the pattern to lower reactivity, not to classify.
4. To reduce reactivity by seeing the pattern
   In Bowen therapy the genogram is a tool for thinking: seeing a multigenerational pattern of cutoffs over money helps each partner step back from automatic reactivity.

An EFT therapist says to a withdrawing husband, “Maybe when she gets loud, a part of you feels like you're failing her, and going quiet feels safer?” This intervention is:

1. Heightening
   Heightening intensifies an emotion that is already present, for example by repetition or imagery; here the therapist proposes a feeling not yet voiced.
2. Transference interpretation
   Transference interpretation links feelings toward the therapist to past relationships, which is psychodynamic, not EFT.
3. Empathic conjecture
   Offering a tentative guess at the feeling just beyond what the husband has said (failing her, safer to go quiet) is EFT empathic conjecture.
4. Reframing
   Reframing places behavior in a new frame, such as the cycle being the enemy; this statement guesses at an inner experience instead.

A 9-year-old was sexually abused by a neighbor; the abuse was reported and she is now safe. She has nightmares and avoids going outside. Which treatment has the strongest evidence and actively involves her non-offending parent?

1. Single-session critical incident debriefing
   Single-session critical incident debriefing is not recommended and can worsen outcomes; it also leaves the parent out.
2. Trauma-focused CBT with the caregiver
   TF-CBT has the strongest evidence for child PTSD after sexual abuse and actively includes the non-offending caregiver in parenting skills and conjoint sessions.
3. Nondirective play therapy on its own
   Nondirective play therapy alone has weaker evidence for PTSD and does not systematically involve the caregiver.
4. Parent-child interaction therapy
   Parent-child interaction therapy targets disruptive behavior in young children, not trauma symptoms after abuse.

A skeptical father says therapy has never worked for his family. The MRI therapist replies, “You may be right. I'm not sure I can help, but I'd value your view of what's gone wrong.” This is BEST described as:

1. A paradoxical directive
   A paradoxical directive instructs the family to do the symptom; this is a stance, not a directive.
2. Restraining change
   Restraining change warns the family against changing too fast; this remark lowers the therapist's status instead of cautioning against change.
3. A one-down stance
   Downplaying the therapist's expertise and inviting the father's view is the MRI one-down stance, which lowers his need to resist.
4. Positive connotation
   Positive connotation gives the family's behavior a benevolent purpose; the therapist here comments on their own limits, not on the family's motives.

A 52-year-old woman caring for her mother with dementia while raising two teenagers is exhausted. Her two brothers live nearby but rarely help. What is the MOST appropriate systemic intervention?

1. Coach her to set firmer limits with the teens
   Firmer limits with the teenagers target the wrong subsystem; the gap is in sibling caregiving.
2. Convene the siblings to share caregiving
   Her exhaustion reflects how the wider family has divided the work, so convening the siblings to renegotiate caregiving addresses the system that leaves her overloaded.
3. Teach her individual stress-management skills
   Individual stress-management skills treat the overload as her coping problem and leave the brothers' absence unchanged.
4. Advise moving her mother to a nursing home
   Advising nursing-home placement imposes a decision that belongs to the family and skips the unequal division of labor.

A 14-year-old with repeated shoplifting and his parents start functional family therapy. The parents open by listing his failings, and he answers with sarcasm. In FFT's engagement and motivation phase, the therapist relies MOSTLY on

1. reframes that reduce blame and negativity
   FFT's engagement and motivation phase relies on relational reframes that cut blame and negativity, building an alliance with every member before any change is asked for.
2. links to school and community supports
   Linking the family to school and community supports is the generalization phase, which comes last.
3. behavior contracts with consequences
   Behavior contracts with consequences belong to FFT's later behavior change phase; offered amid open blame, they feel like taking the parents' side.
4. cognitive skills training for the teen
   Cognitive skills training for the teen is behavior change work and singles him out while blame is still high.

Since her father left, a 13-year-old cooks, handles bills and comforts her mother at night. A contextual therapist would MOST likely

1. praise her maturity as a family strength
   Praising her maturity as a strength reinforces the parentified role and the imbalance.
2. credit her giving and restore a fair give-and-take
   Contextual therapy sees parentification as an unfair ledger: the therapist credits what the girl gives and helps the mother take back parental tasks, restoring fair give-and-take.
3. coach her to set firm limits with her mother
   Coaching a 13-year-old to set limits with her mother puts the burden of change back on the child.
4. ask the mother to hire help with household bills
   Hiring help with the bills addresses one chore, not the relational ledger or the girl's role as her mother's comforter.

Parents describe their 16-year-old as "rebellious and disrespectful" because she argues about every rule. Which reframe BEST opens an alternative perspective for the family?

1. "You may be too strict for a girl her age."
   Calling the parents too strict shifts the blame to them instead of offering a new meaning that the whole family can accept.
2. "She's practicing standing up for herself."
   Reading the arguing as practice in standing up for herself gives the behavior a new, plausible meaning tied to a normal developmental task, which invites different responses.
3. "She may have a disorder we should rule out."
   Raising a possible disorder narrows the view to pathology rather than opening a new perspective.
4. "All teens argue; it passes if you ignore it."
   Telling the parents to ignore it dismisses their concern; it is advice, not a reframe.

In a family where the father dominates and the mother's views are routinely dismissed, a structural therapist deliberately sides with the mother for a time to challenge the family's hierarchy. This technique is

1. joining
   Joining builds an alliance with every member in order to enter the system; it does not side with one member against another.
2. multidirected partiality
   Multidirected partiality (contextual therapy) means being fair to each member in turn, the opposite of deliberately siding with one.
3. detriangulation
   Detriangulation removes a third party from a two-person conflict; here the therapist enters the conflict on purpose.
4. unbalancing
   Temporarily siding with one member to shift the family hierarchy is Minuchin's unbalancing, a restructuring technique.

A therapist asks a father, "If your son started to trust you again, how might that change the way you talk to him?" In Karl Tomm's framework, this is

1. a reflexive question
   A hypothetical, future-oriented question that invites the father to imagine a new possibility is what Tomm calls a reflexive question.
2. a strategic question
   Strategic questions are leading and corrective, pushing toward the therapist's preferred answer; this one is open-ended.
3. a lineal question
   Lineal questions investigate causes in a straight line ('Why did he stop trusting you?'); this one invites imagining a future.
4. a circular question
   Circular questions explore existing patterns and differences ('Who notices first when he withdraws?'); this one asks about a hypothetical future.

A therapist seeing a 30-year-old woman individually for depression learns that her husband's drinking and criticism are central to her low mood. Which step BEST fits?

1. Refer her husband to his own therapist only
   Referring the husband out only removes his drinking and criticism from the work that involves her depression.
2. Continue individual CBT and avoid the marriage
   Continuing individual CBT while avoiding the marriage ignores a central maintaining factor.
3. Tell her that the marriage causes her depression
   Telling her the marriage causes her depression is a premature, linear claim that she may experience as blame.
4. Discuss inviting her husband to some sessions
   When a relationship maintains an individual's symptoms, the therapist raises the option of conjoint sessions and lets the client decide whether to invite her husband.

In a Gottman Method session, a wife says, "You never help. You're so lazy." Her husband replies, "I did the dishes yesterday!" Which intervention BEST targets the wife's statement?

1. Coach a gentle start-up of her complaint
   'You never help, you're so lazy' is criticism, an attack on character, and Gottman's antidote to criticism is a gentle start-up: a feeling and a specific request without blame.
2. Call a 20-minute break for physiological soothing
   A 20-minute break for physiological soothing is the remedy for flooding, which the stem does not describe.
3. Coach him to accept responsibility for part of it
   Accepting responsibility is the antidote to defensiveness, which is the husband's reply; it does not target the wife's statement.
4. Build a culture of fondness and admiration
   Building fondness and admiration is the antidote to contempt and a long-term foundation, not the direct fix for a critical start-up.

A wife criticizes loudly in session. The EFT therapist asks what she feels just before she raises her voice, and she says, "Alone, like I don't matter to him." This intervention accesses:

1. The primary emotion beneath her anger
   Asking what she feels just before she gets loud reaches the primary attachment emotion (loneliness, not mattering) beneath her reactive anger.
2. Her family-of-origin loyalty pattern
   A family-of-origin loyalty pattern is a contextual-therapy concept; the question targets her feeling in the present moment.
3. A cognitive distortion to be challenged
   EFT does not treat 'I don't matter to him' as a cognitive distortion to dispute; it is an attachment feeling to be heard.
4. A skills deficit in emotional expression
   Treating the moment as a skills deficit misses the point: the aim is to reach the emotion, not to teach how to express it.

The more a mother tightens rules for their 8-year-old, the more the father loosens them to make up for it, and the child plays one parent against the other. What is the BEST treatment focus?

1. Deciding which style research supports
   Deciding which style research favors makes the therapist a judge between the parents and leaves the cycle running.
2. Teaching the child to follow each parent's rules
   Teaching the child to follow each parent's separate rules accepts the split hierarchy instead of repairing it.
3. Interrupting the parents' polarizing cycle
   Each parent's move provokes the other's, and the child exploits the split; the treatment target is the reciprocal polarizing cycle, so the parents can act as a team.
4. Coaching the father to adopt the mother's rules
   Coaching the father to adopt the mother's rules takes her side and ignores her part in the escalation.

During an enactment, a mother keeps turning to the structural therapist to complain about her 13-year-old son. What is the therapist's BEST response?

1. End the enactment to avoid more conflict
   Ending the enactment to avoid conflict loses the chance to observe and change the pattern in the room.
2. Redirect her to talk to her son
   In an enactment the therapist stays out of the middle and redirects the mother to talk with her son, keeping the interaction between them.
3. Answer her and give advice about her son
   Answering her and giving advice pulls the therapist into a triangle and stops the family from working out its own interaction.
4. Interpret her need to find an ally here
   Interpreting her wish for an ally shifts the focus to insight about her and away from the mother-son exchange.