BEST BEST

NOVEMBER // DECEMBER 2013 

THE AMERICAN ASSOCIATION FOR MARRIAGE AND FAMILY THERAPY 

BEST 

OF THE 

BEST 

Topics and presenters 

you have rated 

the highest! 

Getting creative in the 

therapy room: 

What may seem zany just 

might work! 

page 22 

Hypnotherapy: 

More uses than you may 

have realized 

page 26 

Addiction: 

When the pursuit of pleasure 

and success becomes a 

dangerous habit 

page 32

VOLUME 12, NUMBER 6 

EXECUTIVE EDITOR 

Tracy Todd 

NOVEMBER / DECEMBER 2013, VOLUME 12, NO. 6 

MANAGING EDITOR 

Kimberlee Bryce 

DIRECTOR OF COMMUNICATIONS 

Amanda Darnley 

ADVERTISING 

Shane Lo Maglio 

ANNUAL CONFERENCE PHOTOGRAPHER 

Mike Pablo 

DESIGN AND PRINT 

Good Printers, Bridgewater, VA 

Family Therapy Magazine 

(ISSN 1538-9448) is published 

bimonthly (January, March, May, July, 

September, November) by the American 

Association for Marriage and Family 

Therapy, Inc., 112 South Alfred Street, 

Alexandria, VA 22314-3061. Printed in the 

USA. Periodical mailing from Alexandria 

and additional entry points. ©2013 by the 

American Association for Marriage and 

Family Therapy (AAMFT), Inc. All rights 

reserved. Written permission for reprinting 

and duplicating must be obtained through 

the Copyright Clearance Center at 

www.copyright.com. 

The articles published in the Family 

Therapy Magazine are not necessarily the 

views of the association and are not to be 

interpreted as official AAMFT policy. 

Submission of manuscripts: Manuscripts 

may be submitted electronically to FTM@ 

aamft.org or mailed to: Editor, Family 

Therapy Magazine, AAMFT, 112 South 

Alfred Street, Alexandria, VA 22314-3061. 

Telephone: (703) 838-9808. Concise 

articles (2000 words or less) are preferred. 

Authors should allow at least two months 

for a decision. 

Advertising deadline for both classified and 

display advertising is approximately eight 

weeks before the month of publication. 

Please call (703) 253-0447 or write to 

slomaglio@aamft.org for exact deadline 

dates and all advertising questions. All 

advertising must be prepaid. 

POSTMASTER: 

Send address changes to: 

Family Therapy Magazine 

112 South Alfred Street 

Alexandria, VA 22314-3061 

Twenty-five percent of this paper is postconsumer 

recycled material and preserves 

17.49 trees, saves 7,429 gallons of wastewater 

flow, conserves 12,387,806 BTUs of energy, 

prevents 822 lbs of solid waste from being 

created, and prevents 1,618 lbs net of greenhouse 

gases. 

22 

26 

32 

Therapeutic Artistry: Finding Your Creative Edge with 

Difficult Couple and Family Practice Situations 

One clinician shares his list of practice strategies for 

cultivating the creative use of self, with the hope to inspire 

you to be more daring, inventive, and improvisational in 

your clinical work with challenging couples and families. 

Matthew D. Selekman, MSW 

Hypnotherapy in Marriage and Family Therapy 

Hypnotherapy is a brief, effective intervention that can 

be employed as a primary therapy or as an adjunct to 

more traditional marriage and family therapies. There is 

increasing evidence that hypnotherapy is an effective tool 

for many different problems, and MFTs who are trained in 

hypnotherapy bring a broad range of skills that can expand 

the scope of practice of MFTs and their client base. 

Gary Elkins, PhD Cassie Kendrick, PsyD 

Behavioral Addictions: Turning It Around 

A family member may be the first to uncover the devastating 

effects of a “hidden” addiction. Since family therapists are 

often on the front line of this discovery, their alertness to 

family “dis-ease” may assist in interrupting the development 

of a behavioral addiction. 

Meri L. Shadley, PhD

Departments 

2 Executive Director’s Message 

6 Noteworthy: Scenes from the 

AAMFT 2013 Annual Conference 

12 Advocacy Update 

40 Ethical & Legal: Gifts, “Thank Yous,” 

and the “Why I Do This” Box, Part 2 

Lisa Rene Reynolds, PhD 

44 Classifieds 

44 Calendar 

ALSO IN THIS ISSUE: 

4 Christine Michaels Celebrates 25 Years at AAMFT 

13 Health Reform: The Latest Developments 

Brian Rasmussen, PhD 

17 The Minority Fellowship Program at AAMFT 

37 Registration Information for 

2014 Institutes for Advanced Clinical Training 

42 Sally Sells Sea Shells by the Seashore 

(The personal story of a child of an alcoholic) 

Merriam Sarcia Saunders, MS 

44 Roles, Rules, Rituals & Eating Disorders 

Alli Spotts-De Lazzer, MA 

LETTERS TO THE EDITOR 

We encourage members’ feedback on issues appearing in the Family Therapy 

Magazine. Letters should not exceed 250 words in length, and may be edited for 

grammar, style and clarity. We do not guarantee publication of every letter that 

is submitted. Letters may be sent to FTM@aamft.org or to Editor, Family Therapy 

Magazine, 112 South Alfred Street, Alexandria, VA 22314-3061.

[ a message from the executive director ] 

No Reason to Lack Connections 

“A beautiful thing happens when we 

start paying attention to each other. 

It is by participating more in your 

relationship that you breathe life 

into it.” 

– Steve Maraboli, Unapologetically You: Reflections 

on Life and the Human Experience 

Vibrancy, energy, and invigoration are creations of 

communication, interaction, and engagement. It is 

an exciting time in AAMFT’s development, as never 

before have there been so many platforms for debate 

and collaboration. Nor have there been so many 

different topics open for discussion. A quick perusal 

of some of AAMFT’s more active platforms finds some 

great discourse. 

LinkedIn 

Possibly the most active of AAMFT social media 

platforms, debates and chats include: 

• Why do you think Western culture is experiencing a 

literal epidemic of anxiety? 

• Can a marriage be saved after an affair? 

• Tips on passing the MFT exam. 

Within the AAMFT Community, more specific MFT 

and behavioral health postings can be found. Clinical 

Fellows, like Robert Marrs and Benjamin Caldwell, 

present pithy and provocative posts: 

• Client confidentiality, HIPAA and coordination of 

care are given careful examination. 

• “Whose Conscience Matters? The role of emerging 

‘conscience clause’ laws in family therapy” invites 

members to discuss the issues presented in the 

September/October Family Therapy magazine. 

AAMFT Facebook 

Equally compelling discussions can be found involving 

advocacy and credentialing: 

• Should you receive drug and alcohol credentials 

before becoming an MFT? 

• Sentiments about the Pennsylvania State House 

passing a bill requiring mental health training for 

police officers and district judges. 

Executive Director – Twitter 

I recently hosted my first “Twitter Town Hall Chat” 

involving AAMFT conference programming. After 

notifying members and sending invites, this small but 

active chat provided some great kick around of ideas 

about conference programming in the future. Some 

extracts from the Twitter chat are on page 4. 

Not only are our members and non-members 

engaged in interesting discussion topics, but the 

AAMFT Board and staff are working hard to keep 

information flowing. 

• President Chafin reported on AAMFT 

Board activities from the October 

meeting: 

www.aamft.org/Oct2013boardreport. 

• During the AAMFT annual conference, 

the business meeting addressed the 

current status of AAMFT, as well as some 

exciting future events: 

www.aamft.org/2013annualbusinessmeeting. 

• AAMFT has also been keeping members informed of 

association health via the Scorecard: 

www.aamft.org/management. 

2 FAMILY THERAPY MAGAZINE

As we all continue to learn the distinctions between 

transparency, privacy, and secrecy, AAMFT will work hard 

to provide members with information frequently without 

becoming “spammers.” I personally invite you to become an 

active voice on any of the AAMFT platforms. 

• AAMFT Community 

• AAMFT Facebook 

• AAMFT Twitter 

• AAMFT LinkedIn 

• Executive Director Facebook 

• Executive Director Twitter 

• Family Therapy magazine 

• Email 

• Telephone 

• Verbal conversations at meetings and conferences 

Changing subjects… 

2013 was a transitional year for AAMFT. AAMFT started 

the year with a new strategic plan and I became executive 

director. I have made every effort to keep the transitions 

smooth, transparent, and create an environment that is 

inclusive and welcoming. Many of you have contributed 

heartily in helping me along the way. For this I say, 

“Thank you.” 

Thank you to so many members providing encouragement, 

support, and ideas for the association. 

Thank you to the AAMFT Board of Directors for believing in 

me a year ago and providing the resources to help establish 

AAMFT as the premier association for marriage and family 

therapists. 

Thank you to an incredible staff who, over the last year, 

needed to go meet that little clause in everyone’s job 

description “and other duties as assigned.” The dedication 

and integrity demonstrated has been nothing short of awe 

inspiring. 

Finally, chief operations officer Chris 

Michaels is celebrating 25 years with 

AAMFT. Her knowledge, wisdom, and 

insight is a true benefit to members and 

staff. Thank you Chris for your dedication 

and service to AAMFT. 

—Tracy Todd, PhD 

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NOVEMBER/DECEMBER 2013 3

Be informed 

& contribute 

@TheAAMFT 

http://twitter.com/TheAAMFT 

General information about 

public events, marriage and 

family therapy, announcements 

@TTODDMFT 

https://twitter.com/TToddMFT 

Information from the ED about 

the AAMFT and events that 

directly impact marriage and 

family therapists 

Facebook 

AAMFT 

http://www.facebook.com/ 

TheAAMFT 

TTodd 

http://www.facebook.com/ 

TtoddMFT 

LinkedIN 

You can find AAMFT on LinkedIn 

in two different capacities: 

AAMFT Group 

http://tinyurl.com/AAMFTLI 

Company Page 

http://tinyurl.com/AAMFTpage 

AAMFT Website 

www.aamft.org 

AAMFT Community 

www.aamft.org/Community 

Following are some 

extracts from the 

Twitter chat: 

Tracy Todd We are addressing the issue of having a balanced reviewed 

conf program w/invited high quality & trending presentations. 

Arnold Woodruff: I’d like some balanced presentations on the medical 

model – Alan Francis and Robert Whitaker e.g. 

Sarah Woods: Wonder about value of matching reviewers’ areas 

of expertise w/ abstracts they review—increase chances of quality 

presentations? 

Arnold Woodruff: Also tend to be a bit redundant! 

Tracy Todd: Better matching for example, quantitative researcher w/ 

quantitative submission not qualitative. 

Tracy Todd: We anticipate decreasing redundancy with invited 

presentations. Which leads to a question… 

Tracy Todd: After ranking abstracts high to low, should those below a cutoff 

score be added so that diverse topics get represented? 

Arnold Woodruff: We should try to pick presentations that enhance the 

brand (once we have one). 

Arnold Woodruff: Try to get press coverage, maybe some controversy, but 

staying in line with systemic ideas. 

Tracy Todd: agreed. Understand the unintended consequence might be 

less selection of highly ranked abstracts. 

Tracy Todd: Def press coverage next year. We need print media leading to 

the conf to get press covg. Which we will work on. 

Arnold Woodruff: But it seems that many highly ranked abstracts haven’t 

been great workshops. 

Arnold Woodruff: I’m not ready to go back to DS picking everything, but we 

did have some exciting stuff then. 

Tracy Todd: People can write well, but present poorly. Others write poorly, 

but present well. That is the challenge. 

Arnold Woodruff: Need to use participant rankings if previously presented, 

then. Still need to make room for newbies. 

Tracy Todd: Invite only allows the selection of great pres/topics. The cost is 

abandoning those trying to break into the field. 

Arnold Woodruff: Right. Back to some invited, some blind select. No 

perfect answer, I don’t think. 

Tracy Todd: So AAMFT needs to work on a ratio of invite/known presenters 

to abstract reviews/newbies over the next few years 

Tracy Todd: thank you for recognizing that. We are determined to find the 

right balance over the coming years. 

Tracy Todd: Special thank you to Arnold Woodruff and Sarah Woods for 

your participation. 


25! 

Chris 

AAMFT Celebrates the Silver 

Anniversary of Chris Michaels 

currently serves as AAMFT’s chief 

operations officer. She previously held 

the title of director of business systems. 

Chris is an integral part of the AAMFT 

staff, and for 25 years she has worked 

in all aspects of office support, from our 

accounting system, to technology, and 

all office systems (phones, computers, 

and everything else!). Chris’s efforts and 

influence can be found throughout our 

operation. We hope you will join us in 

congratulating Chris on her career-long 

service and dedication to AAMFT. 

Christine Michaels recalls 

living in Montgomery County, 

Maryland, as she began a 

job search after college. 

She majored in math and 

economics, and figured a good 

fit would be something in 

the area of finance, insurance, or banking. She 

spotted an ad for an accounting clerk position at 

AAMFT. She immediately felt encouraged by the 

mission of the organization and loved the small 

staff size. In those days, the office was small 

and cramped, but the location in downtown 

Washington, DC offered excitement. Chris 

admits she would like to say she took the job 

because it was in her field and paid well, but the 

reality on the day she got the call was that her 

bank account had hit zero. The choice was to 

take the position or pack all her things and head 

back home to mom and dad. She could never 

have guessed on that day that her quick decision 

would have such a major impact on her career, 

life, and on this organization. 

All states have an MFT license, and there have 

been numerous programs added over the years. 

Chris noted of her tenure, “I have had the 

pleasure of working with so many great and 

smart people over the years; people who are 

committed to helping their clients, particularly 

given their long and continued fight to be 

recognized in the mental health community.” 

We hope to be commemorating Chris’s golden 

anniversary one day. Thank you, Chris, for all 

your years of hard work, guidance, expertise, 

patience and friendship! 

Chris Michaels was born in Baltimore, MD, and 

raised in various locations in Maryland. She 

graduated from Western Maryland College (now 

called McDaniel College) in 1988 and joined 

the AAMFT staff. Chris earned her certified 

association executive (CAE) credential in 2006. 

She was most recently promoted as AAMFT’s 

COO in 2013. 

Chris has been around since 

AAMFT was a small association 

of 13,000 members. In her early 

years, members were from 

many different professions and 

saw the AAMFT as a secondary 

membership; there were 

only 13 licensed states and very few training 

programs. Now, most members identify as 

LMFTs and AAMFT is their primary membership. 

Executive Director Tracy 

Todd, PhD, presents Chris 

with a beautiful crystal bowl 

on behalf of AAMFT. 

5

noteworthy 

Scenes from AAMFT13! 

Raising Vibrant Children 

In case you missed it, here are some shots from the 

Annual Conference held recently in Portland, OR. 

Don’t miss next year’s event in Milwaukee, WI. 



noteworthy 



noteworthy 



advocacy 

update 

Health Reform Exchanges’ Launch Marred by 

Computer Glitches and Lack of Provider Lists 

ON OCTOBER 1ST, under the Affordable Care Act (ACA, 

also called ObamaCare), uninsured people in families with 

incomes between 133% and 400% of the federal poverty level 

became eligible for federal financial subsidies if they enroll 

in the new Exchange healthcare coverage plans (also called 

Marketplace plans), effective January 1. Fourteen states and 

the District of Columbia are running their own exchanges, 

while the federal government is running exchanges in the 

other 36 states. All of these Exchanges had major computer 

problems in the first weeks of operation, delaying users from 

enrolling and from choosing coverage plans. 

At least 170 insurers are offering at least 4,400 Qualified 

Health Plans (QHPs) on the Exchanges. Due to the design 

of Exchange websites, at deadline only the Maryland 

and Minnesota Exchanges allowed users to browse QHPs’ 

participating provider lists. Some QHPs in both those states 

include some private-practice MFTs. But QHP provider lists 

are much smaller than is typical for employer-sponsored 

health plans, a situation called “narrow” networks. There 

are scattered reports that some providers who signed QHP 

contracts are not being listed in QHP provider networks, 

while other providers who did not sign up are nevertheless 

being listed. 

The Congressional Budget Office predicts about 7 million 

uninsured persons will enroll in QHPs in 2014. In addition, 

because most of the 18 million people who now have 

individual (non-group) coverage will lose that coverage 

in 2014 (as their current plans don’t meet new federal 

standards), many of those people also will enroll in 

Exchange plans. The ACA requires most citizens to have 

health insurance by April 1, 2014, or face a financial penalty 

of the greater of $95 per person or 1% of a family’s 2014 

modified adjusted gross income (MAGI) for federal income 

tax purposes (e.g., a $300 penalty if MAGI equaled $30,000). 

Federal Fiscal 2014 Budget Impasse 

Bodes Ill for Programs Relevant to MFTs 

BETWEEN OCTOBER 1 and October 17, many federal workers 

were furloughed due to inability of Congress to agree on 

funding “discretionary” (non-entitlement) programs for 

fiscal 2014, which began October 1. Republicans in the 

House of Representatives proposed linking discretionary 

funding to several alternatives that would have impeded 

implementation of the Affordable Care Act (ACA). 

Although all clinicians (including MFTs) working for the 

federal Department of Veterans Affairs (VA) were exempt 

from this shutdown, other civilian clinicians—such as those 

at the Department of Defense—were furloughed. Congress 

finally agreed to a Continuing Resolution (CR) that runs 

through December 15. Congress subsequently voted to pay 

furloughed workers for their lost time. 

The HHS/SAMHSA Minority Fellowship Program, through 

which 25 doctoral MFT students are funded, was not affected 

by the shutdown. However, under the 2011 Budget Control 

law, starting January 1 nearly all discretionary programs 

will again be subject to across-the-board funding cuts, a 

process called sequestration. Both parties in Congress say 

they want to stop sequestration, but at deadline no deal to 

do so was imminent. Some in Congress say they want to stop 

sequestration by instead cutting entitlement programs such 

as Medicare and Medicaid. 


HEALTH REFORM 

THE LATEST 

DEVELOPMENTS 

Brian Rasmussen, PhD 

In the September/October FTM, we looked at factors that 

private practice MFTs should consider in responding to the 

Affordable Care Act’s (ACA) many changes in healthcare 

financing. This article will address recent developments 

and their effects on MFTs, and answer two more complex 

operational questions from MFT private practitioners. 

Status of Marketplace (Exchange) Health Plans for 

Uninsured Persons 

On October 1, enrollment in these plans became open to 

all uninsured persons. All of these Exchanges (state-run in 

14 states and the District of Columbia; federally-run in the 

remaining states) have encountered computer glitches, but 

because coverage doesn’t start until January 1, 2014, there 

is time to correct at least some of those problems. 

To help pay insurance premiums, uninsured persons in 

families with Modified Adjusted Gross Incomes (MAGI, 

as reported on 2012 Federal Income Tax forms) between 

133% and 400% of the Federal Poverty Level are eligible 

for sliding-scale federal financial subsidies. (In 2014, for 

a family of 4 in the Lower 48 States, the subsidized MAGI 

range is $31,332 to $94,200 annually; higher in Alaska 

and Hawaii.) 

The Obama Administration projects that 7 million persons 

will enroll in these plans by March 31, the last day on which 

enrollment for any period in 2014 is allowed. Although 

this figure is less than half of all eligible persons, the 

Administration projects that not all eligible people will 

enroll in 2014 due to a variety of factors. Enrollment is 

expected to increase in later years. 

One or more insurers have been approved to offer Qualified 

Health Plans (QHPs) in each State’s Marketplace (also known 

as the Exchange). These plans offer four basic levels of 

coverage—Bronze, Silver, Gold and Platinum. Bronze plans 

have the lowest premiums, but the highest enrollee costsharing, 

and vice-versa for Platinum plans. It’s expected 

most enrollees will choose Bronze plans. 

Blue Cross and Blue Shield companies are offering 

QHPs in virtually all states, with many fewer offered by 

commercial insurers such as Aetna, local health maintenance 

organizations, and non-profit cooperative (CO-OP) firms (see 

www.aamft.org/HealthReformStatesDatabase to see details 

for your state). QHPs may operate on either a statewide or 

sub-state basis. 

The law also requires the federal Office of Personnel 

Management (OPM) to establish two so-called “multi-state” 

or “national” Exchange plans. For now, it appears that 

in 2014 there will be at least one such plan in 31 states, 

operated by the Blue Cross Blue Shield system (see the 

previously-cited website for relevant states). These Blue 

Cross “multi-state” plans will have somewhat different 

details than the state-specific QHPs that Blue Cross also will 

run in most states. 

In addition, for uninsured workers (and their family 

members) employed at firms with 50 or fewer full-time 

employees, special plans are available through ACA’s 

Small Business Health Options Program (SHOP). Such 

employers who pay for at least part of SHOP plans’ costs 

may be eligible for a federal tax credit of up to 50% of the 


employer’s payment. However, in some 

states, only one SHOP plan will be 

available in 2014, and in others, none 

will be available then. 

Exchange Plans Limit Choice of 

Hospitals and Private Practices, 

and Pose Bad-Debt Problems 

As of this writing, provider network 

lists were not available for most 

QHPs. One reason for this is that all 

but Minnesota’s Exchange website 

require applying for coverage before 

one has the opportunity to see each 

insurer’s provider lists. Some Minnesota 

insurers offering QHPs, such as UCare, 

do include MFTs affiliated with local 

clinics. For other Minnesota insurers, 

the provider list does not specify if 

practitioners are MFTs versus other 

masters-minimum clinicians. 

And it is difficult online to find 

Minnesota insurers’ provider lists, 

meaning enrollees are very unlikely 

to choose a plan based on it including 

a specific MFT. Indeed, the online 

Exchanges in nearly all states 

are structured to emphasize QHP 

premium and federal subsidy amounts, 

supporting the widespread prediction 

that most enrollees will choose based 

on low price. Lowest-priced (Bronze) 

plans have very high deductibles 

(typically $2,500 to $6,300 for an 

individual) and client cost-sharing 

(typically 50% or higher). This could 

well create substantial bad debts for 

providers. 

Under a federal regulation (45 CFR § 

156.230), provider lists are supposed 

to be available to the public, but that 

rule does not address exactly when 

this is required. Although most QHPs 

did not have provider lists available 

at deadline, news articles based on 

provider self-reports indicate many 

plans have “narrow” (very limited) 

networks. For example: 

• In Missouri, Anthem Blue Cross, 

which covers the state except for the 

Kansas City area, excludes at least 13 

hospitals from its QHPs. 

• Of New Hampshire’s 30 hospitals, at 

least 10 are excluded from Exchange 

plans. 

• In Illinois, Indiana and New York, 

multiple large hospitals are excluded 

from one or more QHPs in each state. 

Hospitals account for a large share of 

total health spending, so “wholesale 

pricing” by excluding some from 

Exchange plans is economically 

obvious. MFTs at QHP-contracted 

hospitals may see more clients; 

MFTs at other hospitals may well see 

fewer (because some consumers with 

employment-based coverage will be 

transitioned to Exchange coverage, thus 

current managed-care contracts will 

yield fewer clients). 

ACA also cuts Medicare and Medicaid 

pay rates for acute-care hospitals by 

$155 billion over 10 years. (The hospital 

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industry accepted this cut on the 

premise it would be offset by revenue 

from new Medicaid and Exchange 

enrollees, but that offset won’t happen 

in many cases.) These pay cuts may 

cause hospital-based MFTs to be required 

to “do more with less.” 

And as QHP-excluded hospitals 

are highly visible in their local 

communities, their exclusion implies 

that small clinical offices, such as 

those of most private-practice MFTs, 

also have been excluded. 

Potential Remedies When Private- 

Practice MFTs Are Excluded from 

QHP Provider Networks 

An insurer offering QHPs may use one 

or more of its existing (employersponsored 

plan) provider networks, 

but more likely has a network with 

fewer providers. This raises the issue 

of what private practice MFTs can do if 

they are turned down for QHP network 

participation. 

Unfortunately, the law offers few 

options. ACA Section 2706 states that 

QHP insurers may not discriminate 

against any class of practitioner. But 

the Obama Administration has decided 

not to issue any regulations to enforce 

this provision because “that provision 

is self-enforcing.” AAMFT has protested 

this lack of regulations to federal 

officials. The Administration advises 

aggrieved practitioners to contact their 

state government’s insurance agency 

to seek enforcement. However, some 

Republican-led states such as Texas have 

said their states will not be involved in 

enforcing any ACA provisions. 

Despite this, there may be legal 

remedies, but their use will be 

challenging. Thirty-one states (see 

www.aamft.org/state_awp) have rules 

requiring state-regulated insurance 

plans not to discriminate against MFTs 

by practitioner type (“vendorship”), or 

to allow any willing provider (AWP)— 

including MFTs—to contract, or 

both. However, the legal applicability 

of these rules to QHPs is unknown 

because it is unclear if federal law will 

override any relevant state rules. 

As a result, it likely will be necessary 

to establish precedents through 

litigation (“case law”), a costly and 

time-consuming process. On the one 

hand, a favorable decision about 

including chiropractors or physical 

therapists likely will be a good 

precedent for MFTs. On the other 

hand, the delay until such cases are 

decided could result in a private MFT 

practice being forced to close, due to 

lack of QHP contracts, coupled with 

insurers’ reduced payment rates for 

other clients. It also is unclear whether 

a favorable decision in one state would 

be legally relevant to others. 

Yet there may be additional legal 

options. For example, Washington 

State requires QHPs to treat all mental 

health and substance-use providers 

as Essential Community Providers, 

meaning those who have preferential 

status for contracting purposes. 

Status of Medicaid Expansion 

About half the states have 

chosen not to expand Medicaid 

in 2014 (see www.aamft.org/ 

HealthReformStatesDatabase), and three 

(Arkansas, Iowa, and Pennsylvania) will, 

or are expected to, expand Medicaid 

under special “waiver” authority by 

enrolling their “Medicaid expansion” 

residents into the relevant state’s 

exchange system. In states that do not 

expand Medicaid, the law’s Individual 

Mandate that uninsured persons either 

obtain coverage or pay a fine will not 

apply to “Medicaid expansion” residents. 

Because private MFTs are Medicaideligible 

in only about half the states 

(often with restrictive requirements), 

and Medicaid programs generally have 

low payment rates, Medicaid expansion 

will be less relevant than Exchanges for 

most private MFTs. 

Q&A 

Q1: I’m a solo private practitioner 

who speaks only English. Can Medicaid 

or Exchange plans bar me from 

contracting due to this, and if I am 

referred a client who’s not fluent in 

English, must I treat that client and 

pay for translation services during 

sessions? If I use an interpreter, what 

about confidentiality? What if a non- 

English-speaking family member is 

involved in a treatment session? 

A:An estimated 42% of persons who 

will enroll in ACA’s Medicaid and 

Exchange plans regularly speak a 

language other than English, including 

39% who speak Spanish. But some 

of these people also are fluent in 

English. ACA Section 1557 specifies 

that ACA-funded healthcare entities 

may not discriminate based on factors 

such as race or ethnicity, and this 

includes “limited English proficiency” 

(LEP). Providers are required to take 

“reasonable steps” to comply, and 

because of situational considerations, 

further guidance is available at 

http://www.hhs.gov/ocr/civilrights/ 

resources/laws/revisedlep.html and 

http://www.lep.gov/. For example, 

some LEP persons can speak basic 

English, while others cannot. 

If you are denied an Exchange plan 

contract, the plan is not required to 

state the reason(s), and even if lack 

of fluency in another language were 

the cause, that may be considered 

appropriate in view of the need for 

some therapists who speak languages 

other than English. 

On the other hand, many private 

insurers address language barriers by 

having contracted providers list their 

fluency in non-English language(s), so 

that clients fluent in such languages 

may self-select those practitioners from 

the insurer’s provider directory. For 

those insurers, practitioners’ fluency 

in other languages is an asset, but not 


a requirement. In some cases, your 

provider contract may allow you to 

decline clients who are LEP. 

Although the AAMFT Code of 

Ethics does not address the use of 

interpreters specifically, you can look 

to Subprinciples 1.1, 1.2, 1.12, 2.1 

and 2.2 for guidance on issues related 

to non-discrimination, informed 

consent and confidentiality. For further 

guidance on working with LEP persons 

and interpreters, you can refer back 

to the links provided earlier in this 

section or members can contact AAMFT 

for a legal/ethics consult at 703-838- 

9808 or ethics@aamft.org. 

Also be aware that some states, such 

as California, require all licensed 

healthcare providers to meet LEP-client 

standards beyond those of ACA. 

Q2: I’m a solo private practitioner, 

and my state’s private insurance 

market is dominated by one insurer. 

I’m already contracted in this insurer’s 

provider panels for its private plans. 

The insurer will permit (not require) 

me to contract with its Exchange 

plans, the only such plans that will 

operate in my state, but, the insurer 

will reduce my payment rates for all 

its enrollees. It justifies those rate 

cuts because I might get additional 

clients from its Exchange enrollees if 

I contract for those plans. Even if I 

decline the Exchange plans, the insurer 

will nonetheless cut my pay rates for 

its private plans. I don’t think I can 

stay in operation under the lowered 

pay rates, even if I do sign with the 

Exchange plans and obtain more clients 

up to my scheduling capacity. What 

can I do? 

A: This insurer is not forcing you 

to contract with its Exchange plans 

in order to stay on its private plan 

panels, so that would not seem an 

unlawful “tying arrangement.” Unless 

an insurer is guilty of such anticompetitive 

actions, it can reduce pay 

rates at any time and to any levels 

that are permissible under its provider 

contracts and any other applicable 

legal constraints. 

If you sign with the Exchange plans, 

you likely will obtain added clients, 

whose payments would partly offset 

the overall pay-rate cuts, though you 

would need to work more hours. You 

should weigh at least two scenarios to 

see if that might work financially. 

For example, assume you are willing to 

work 10 additional one-hour sessions 

per week. You already have been told 

the insurer’s average allowed payment 

for each such session (e.g., $X for CPT 

90837, “Psychotherapy, 60 minutes 

with patient and/or family member”). 

Now, assume exchange clients would 

fill either 4 or 8 of those 10 sessions. 

You then find that your gross 

additional allowed payments likely 

would be somewhere between four and 

eight times $X. From that amount, 

now subtract your usual bad-debt 

write-off factor for some clients who 

don’t remit their copayments, and you 

derive an expected range of additional 

weekly income. Is it enough to offset 

the weekly income lost from the lower 

rates under your existing contracts? 

Another option is for you to document 

to the insurer’s provider relations staff 

why you are particularly valuable. 

Among possible reasons are that you: 

• serve a rural locale lacking nearby 

therapists (check the insurer’s 

provider directories); 

• offer specialized services such as 

pediatric behavioral therapy; and 

• document that your clinical practice 

patterns and/or client satisfaction 

are very good. For instance, in the 

past year, what was the average 

number of visits for your clients 

with anxiety disorders, and is that 

lower than national or local norms? 

Insurers have wide discretion in 

choosing providers, and such factors 

can result in a special exception. 

There also is strength in numbers. 

Some therapists may adapt to health 

reform by merging into group practices. 

Others may set up provider-run multitherapist 

networks in order to bargain 

collectively with insurers. Still others 

may choose to become employed by a 

larger entity such as a hospital, where 

there is no need to struggle with 

financial issues. All of these approaches 

are increasing among physicians and 

other non-physician practitioners 

Outlook 

In 2014, many questions about the law 

will begin to be answered. The most 

important of these questions is: will 

younger and healthier people enroll in 

numbers sufficient to cross-subsidize 

older and sicker enrollees, as the law 

requires? If a sufficient number of 

younger and healthier people don’t 

enroll, insurers will lose money, likely 

drop their Exchange plans, and the 

entire system could collapse. 

In 2015, additional parts of the law 

are scheduled to start, notably the 

availability in the Exchanges of lowcost 

“basic” plans for certain young or 

very low-income persons, and of SHOP 

plans in those states lacking them in 

2014. 

Health reform will continue to be a 

work in progress for years, and only 

over time will all its outcomes become 

clear. Good luck, and inform AAMFT 

of any good or bad experiences at 

advocacy@aamft.org. Look for updates 

in future issues of FTM. 

Brian Rasmussen, 

PhD, is the 

government affairs 

manager at AAMFT. 


THE AAMFT 

MINORITY 

FELLOWSHIP 

PROGRAM 

For the first time in US history, non- 

Hispanic whites now account for a minority 

of births (US Census Bureau, 2012). The 

growth of the ethnic minority population 

in the United States has been a continuous 

trend in the past decade, and is projected to 

continue well into the future. However, many 

of these ethnic minority groups face barriers 

in seeking the help they need in the area of 

mental health and substance abuse. These 

barriers typically include reduced access, for 

a variety of reasons, to culturally sensitive 

mental health/substance abuse services. To 

address the latter, the federal government 

sought to expand consumer eligibility and 

geographical coverage for current mental 

health services, while also increasing the 

number of qualified behavioral health 

practitioners who serve minority populations. 

Through behavioral workforce development 

grant programs like the Substance Abuse 

and Mental Health Services Administration’s 

(SAMHSA) Minority Fellowship Program 

(MFP), the government is able to devote 

additional resources to increasing the 

number of culturally sensitive practitioners 

for years to come. 

AAMFT was one of a select group of national 

behavioral health associations designated 

to be a recipient of the MFP. This unique 

Fellowship addresses the growing need 

for culturally sensitive behavioral health 

practitioners by providing financial support, 

professional training, and guidance to 

graduate students pursuing doctoral degrees 

in marriage and family therapy. The AAMFT 

MFP is open to marriage and family therapy 

doctoral students who can demonstrate a 

commitment to providing service to and 

conducting research with ethnic minority and 

underserved populations. 

Reference: US Census Bureau. (2012). Most children younger than age 1 are minorities, Census Bureau 

Reports [Press Release]. Retrieved from http://www.census.gov/newsroom/releases/archives/ 

population/cb12-90.html. 

>>> 


Meet the MFP Team 

MFP Training Events 

To aid in the development of a culturally 

attuned behavioral health workforce, the 

AAMFT MFP staff works diligently to ensure 

the continued growth and success of the MFP. 

MFP program director, Dr. Mudita Rastogi, 

provides guidance regarding training issues, 

integrating new developments in the MFT 

field with the expectations of SAMHSA, and 

maintaining relationships with SAMHSA and 

other organizations involved with the MFP. 

Shomari Whittaker, program manager, provides 

operational oversight, support for the activities 

of the program director and the MFP Advisory 

Committee, and support for recruitment and 

strategic partnership initiatives related to the 

MFP. Ryan Gallasch, education specialist for 

the MFP, provides oversight of all day-to-day 

operations related to the smooth running of 

the AAMFT MFP. As the director of educational 

affairs for AAMFT, Tanya Tamarkin provides 

broad financial oversight and compliance with 

policies and procedures and facilitates the MFP’s 

integration into both the academic community 

and AAMFT’s operations. 

From Left: Ryan Gallasch (education specialist), Dr. Mudita 

Rastogi (program director), Tanya Tamarkin (director of 

educational affairs), and Shomari Whittaker (program 

manager). 

In an effort to foster the development of future 

cohorts of practitioners and researchers, 

the MFP has established a unique training 

plan that addresses the needs of its diverse 

Fellows, the wider behavioral health field, 

and the populations it serves. MFP training 

events provide Fellows with a wide array of 

professional development and research training 

opportunities. Fellows are able to network and 

enhance various facets of their leadership skills 

and professional identity through interaction 

with their divisions, state and national level 

advocacy initiatives, and collaboration with local 

and national leaders in the MFT field. 

Additionally, MFP Fellows are able to enhance 

their research and clinical skill sets by learning 

from, and interacting with, leading behavioral 

health researchers and clinicians in the 

areas of culturally sensitive interventions 

with ethnic minority and other underserved 

populations, as well as, training in advanced 

research modalities. Each Fellow receives: 1) 

consultation and individualized guidance on 

their research by an MFP research consultant; 

and 2) recommendations on improving the 

quality of their research. At the annual MFP 

Winter Training Institute (WTI), every Fellow is 

also given the opportunity to present research 

to peers. The feedback generated from these 

trainings has provided Fellows with the input 

and tools needed to generate cutting edge 

and impactful research, and service projects 

to address the need for increased access to 

qualified behavioral health practitioners that 

serve minority populations. 

Over the last few years, Fellow trainings have, 

among many topics, included: 

An Overview of CFT Effectiveness Research: 

Strengths and Areas of Concern 

and discussion 

Douglas Sprenkle, PhD 

Onen Kiwahi: The Indigenous 

Worldview as the Foundation in a 

Practicing Family Therapy Model 

Jann Derrick, MA 

A Gentle Introduction to Structural 

Equation Modeling Jared Durtschi, PhD 

MFP Fellow Corey 

Yeager, University of 

Minnesota, works on 

developing his structural 

equation model at the 

2013 MFP Winter 

Training Institute 

CONTINUED >> 


MFP Mentors 

MFP Fellows also have the unique opportunity of 

working with a diverse group of mentors. MFP mentors 

are, among other things, experienced clinicians, 

renowned behavioral health researchers, AAMFT 

divisional presidents, MFP alumni, and other well 

accomplished academicians—all volunteering their 

time and efforts for the program. Typically, Fellows seek 

mentoring on career guidance, research design, and 

clinical and service issues. The following are just two of 

the MFP mentors from the 2012-13 MFP program year. 

Arnold Woodruff is currently the 

program manager for a series of 

community-based programs in the 

Central Virginia region for individuals 

with serious mental illness. He is also 

an Approved Supervisor and has served 

on the divisional boards in both Virginia 

and Illinois and is currently the past president of the 

Virginia Association for Marriage and Family Therapy. 

Karen Quek, PhD, is an associate 

professor in the Couple and 

Family Therapy Program at Alliant 

International University. She is 

also an Approved Supervisor, and 

a licensed MFT in both California 

and Washington. Her clinical and 

research interests are related to cultural sensitivity 

supervision and training, couples’ process and power, 

and gender construction. 

Sample of Mentors’ 

Areas of Expertise 

Multicultural Competence 

in Clinical Practice 

Research Design 

Supervision 

MFT Scholarship and Publishing 

Evidence-based Practices 

Cultural Adaptation Research 

Federal Grant Writing 

Conducting a Job Search 

Professional Association 

Leadership 

Advocacy on State 

and National Levels 

The Minority Fellowship 

Program had a huge role in 

how I understand the 

meaning of mentorship. 

Darren D. Moore, PhD, 

Mercer University School of Medicine 

MFP Alumni 

Adriatik Likcani, PhD, was 

an AAMFT MFP Fellow from 

2007 - 2009. He now serves 

on the AAMFT MFP Advisory 

Committee, in addition to his 

role as the executive director 

and co-founder of the Recovery 

Lighthouse in Warrensburg, MO. In this position, 

he provides comprehensive re-entry services to 

individuals under the supervision of the Probation 

and Parole Office in local communities. He has 

published in three peer-reviewed journals and has 

presented at the AAMFT annual conference. 

For more information on our MFP Fellows and alumni, visit 

www.aamft.org/MFP. There you can find extended biographies, 

photos, and areas of research and service focus for all our 

MFP Fellows and alumni. 

Zephon Lister, PhD, LMFT was 

an AAMFT Minority Fellow from 

2008–2009. He is an assistant 

clinical professor and director of 

the Collaborative Care Program 

at the University of California, San 

Diego. In this role, he provides 

mental health services and substance abuse 

treatment to clients from Hispanic, Asian, and 

American Indian communities. As a professor, 

he regularly teaches courses in family therapy 

theories, practice of medicine, and health and 

illness in the family. He has presented his model 

of collaborative care at the University of Chicago, 

and has been published in the Oats Journal. 


Dr. Melissa Lewis (2011-12 MFP Fellow) 

Dissertation Completion Fellow on her experience in the MFP 

I was a Fellow in the American Association for 

Marriage and Family Therapy’s Minority Fellowship 

Program. The Fellowship helped me on my way 

to graduating with my PhD in May 2012 from 

East Carolina University in medical family therapy 

(MedFT). Because of my MedFT experience, I 

was fortunate enough to be invited to write two 

articles in the Collaborative Family Healthcare 

Association’s Growing MedFT blog. I authored 

“Research in MedFT Country” and “Exploring the 

‘S’ in BPS (BioPsychoSocial).” 

Doctoral work shows how traumatic stress 

echoes through military families 

My dissertation was on the biological, 

psychological, and relational health of military 

couples. The work centered on the relationship 

between military trauma and relationship quality. 

Its results indicate that through the trauma 

transmission model, civilian spouses experience 

secondary traumatic stress that echoes the 

physiological symptomology of their military 

spouses. Further, secondary stress related to 

marital satisfaction compounds stressful military 

experiences. 

I recently was first author on “Health 

Dynamics of Military and Veteran Couples: A 

Biopsychorelational Overview” in Contemporary 

Family Therapy. I also presented my research in 

a workshop format at the AAMFT 2012 Annual 

Conference, “His and Her Military Marriage: A 

Biopsychosocial Look at Health.” 

Findings on integrated care in Native American 

communities 

My collaboration with other Native American 

marriage and family therapy researchers has 

resulted in multiple presentations (National 

Council on Family Relations, American 

Association of Indian Physicians, and the 

Native Research Network Annual Conference 

in 2012) on medical and behavioral healthcare 

in Native American communities. I presented 

the results of a systematic review regarding 

integrated care (pairing medical and behavioral 

healthcare services) utilization in Native American 

communities. Although integrated care has been 

shown to be effective in improving healthcare 

outcomes in high-needs populations, it has been 

implemented at low rates in Native American 

communities. I also completed a review of the 

literature on culturally competent behavioral 

health interventions for Native American 

communities. I plan to publish the results of both 

projects in spring 2014. I aspire to become an 

advocate for culturally appropriate medical and 

behavioral healthcare screening and interventions 

in Native American communities to reduce health 

disparities. 

Fellowship allowed her to present at annual 

conference of Indian Physicians 

I was able to present at the American Association 

of Indian Physicians annual conference in 

Anchorage, Alaska, because of funding that 

SAMHSA/MFP provided. 

Source: http://www.dsgonline.com/MFP/ 

enews/2012/2012_12_20/mfp_enews_web.html 

I am very grateful for the Minority 

Fellowship, because it allowed me to 

present my research at conferences 

I normally would not have been able to 

attend. My understanding of health 

in Native communities was greatly 

increased by attending 

these conferences 

and by meeting 

exceptional 

researchers in 

the field. 

Melissa Lewis, PhD, is a visiting professor 

at University of Akron (Ohio) in the 

Marriage and Family Therapy program. 


MFP Application Data 

Over the years, the MFP has continued to grow in effort to 

meet the rising need for culturally sensitive therapists. Most 

recently, the MFP saw a nearly 95 percent growth in the 

number of applications received. This growth is attributed 

to the rise of the MFP’s online presence, extensive outreach 

efforts by MFP staff, sophistication in training delivery, and 

the continued accomplishments of each cohort of Fellows. 

The recent expansions of the MFP Alumni Network, the 

addition of a research consultant, and formal expansion 

of the MFP Mentorship Program provides Fellows from 

across the country with the support and skills necessary to 

develop academically and professionally into the nation’s 

future cohort of leading culturally sensitive behavioral health 

practitioners. 

I am so grateful to be in the MFP 

and that I was able to be a part of 

the WTI. Apart from the benefits of 

the workshops and training, many of 

our deep conversations have shaped 

my clinical work in the present and 

career focus. 

Sergio Pereyra, 

Brigham Young University 

I don’t think I would have 

even gotten excited about a 

big project like this if it weren’t 

for the training at the institute. 

I can see myself growing into 

a researcher, where once 

upon a time I was thoroughly 

intimidated by research!” 

Jeni Wahlig, 

Antioch University, New England 

Growth in the number of applications 

received for the MFP over the period: 

2007-2013. 

51 

27 

48 53 59 115 

2007-09 2009-10 2010-11 2011-12 2012-13 2013-14 

Applying for the MFP 

The MFP provides two Fellowship opportunities 

for MFT students—the Dissertation Completion 

Fellowship (DCF) and the Doctoral Fellowship (DF). 

The application process is straightforward and can 

be completed electronically. Detailed information 

is provided on the MFP Application page. Go to 

www.aamft.org/mfp then click on the Application 

link. Applications for the 2014-15 MFP Program 

Year opened mid-December 2013 with a deadline 

of February 18, 2014 and are open to all AAMFT 

members who are full-time graduate students in 

marriage and family therapy doctoral programs. 

As part of the application, students will need to 

provide: 

• Academic information 

• Essay information on their training interests, 

training setting and career goals 

• Dissertation Information (if applying for the DCF) 

• Supplemental Information, this includes: 

• Resume/Curriculum Vitae 

• Unofficial Transcripts 

• Three letters of Recommendation. 

Additional information on eligibility requirements 

for the MFP can be found at www.aamft.org/mfp. 

If you care deeply about providing better 

and more accessible, culturally competent, 

substance abuse and mental health services to 

minorities and underserved groups, we welcome 

your application. Applications for the 2014-15 

Fellowship year are already open. Feel free to visit 

www.aamft.org/mfp for more information. You 

can also contact the MFP staff by writing to mfp@ 

aamft.org. We look forward to hearing from you. 


therapeutic 

artistry 

Finding Your Creative Edge 

with Difficult Couple and 

Family Practice Situations 

Matthew D. Selekman, MSW 


“In each instance, the practitioner allows himself 

to experience surprise, be puzzled, or confused 

in a situation he finds uncertain and unique. He 

is not dependent on categories of established 

technique, but constructs a new theory of the 

unique case. He does not keep means and ends 

separate, but defines them interactively as he 

frames a problematic situation.” 

– DONALD SCHON (1983) 

My first exposure to therapeutic artistry at its best was in the context of 

a week- long live supervision training with Salvador Minuchin in 1986 

(Minuchin, 1986). I brought in one of my toughest families for a live 

family therapy consultation. The family was comprised of 17-year-old 

Tim and his father Allen. The mother had abandoned the family when 

Tim was ten. Tim had had a long outpatient treatment history and two 

psychiatric hospitalizations for psychotic-like symptoms, hallucinogen 

abuse, running away, breaking his father’s rules, and school failure. 

One reoccurring delusion that Tim had was that he was a hippie from 

the sixties and he could assume the identities of famous personalities 

from those times, such as John Lennon, Abbie Hoffman, and so forth. 

Over the four-session period we had seen one another, the goals were 

constantly shifting, agreed upon therapeutic experiments were not 

implemented, and Tim ended up psychiatrically hospitalized. Going 

into this live family therapy case consultation I found it to be quite 

comforting knowing that one of the master family therapy pioneers was 

behind the one-way mirror prepared to help me in the best way possible 

with this highly challenging family. 


Infuse more rhythm into 

your sessions and into your 

daily regime by listening 

to different types of music, 

playing an instrument, 

dancing, engaging in 

artwork, or exercising. 

Minuchin did not waste any time 

like a true artist weaving together 

a beautiful tapestry of metaphoric 

hunches, analogies, vivid imagery, 

humor, surprise, and provocation as 

the final touches to create a workable 

reality in one session. After joining 

with the father and his son, Minuchin 

had discovered that the father used to 

wear his hair long and used to have 

a “wild side” in his younger days 

before cutting his hair and becoming a 

businessman. Minuchin proclaimed that 

they were “The Yuppie and the Hippie.” 

Next, Minuchin began to directly 

challenge the diffused generational 

boundary problem, their problemmaintaining 

interactions, and Tim in 

the role of the symptom-bearer by 

wondering if, when the latter abused 

acid, if he would see images of his 

father in his hallucinations and that he 

and his father were like Corsican Twins. 

Minuchin then challenged Tim by 

pointing out how he was like Zelig, the 

lead character in Woody Allen’s movie 

by the same name. Zelig was like a 

human chameleon who could transform 

himself into a woman, a historic figure, 

a person of color, and so forth. Finally, 

making good use of props in the office 

and humor, Minuchin picked up a 

palmistry hand and held it up to Tim’s 

hand and discovered that he lacked the 

separate line of life and would not be 

able to ever separate from his father. 

This last therapeutic move sparked 

anger in Tim and an outburst from him 

along the lines of “I’ll show you! You 

don’t know what you’re talking about!” 

One week later, when I saw the family, 

the father had reported that Tim had a 

great week and not only did he come up 

with some personal goals for himself, 

but he had landed a part-time job. I 

fell out of my chair with amazement 

after hearing about Tim’s tremendous 

progress. When I had met alone with 

Tim, he reiterated to me that “Dr. 

Minuchin did not know what he was 

talking about!” I said to Tim that he 

was doing a great job of proving the 

good doctor wrong and he confidently 

shared with me that he planned to 

stay drug-free and do better in school. 

In our last family therapy session, we 

celebrated Tim’s high school graduation. 

Another highlight of this incredible 

training experience with Minuchin 

was the short walk we had taken 

together during a coffee break. He 

said to me, “Matt, you need to enjoy 

yourself in there; dance with the 

family.” These encouraging words 

really resonated with me and had a 

profound impact on my becoming 

more daring, playful, provocative, and 

bringing more drama into my work 

with couples and families. Minuchin’s 

artistry also demonstrated to me the 

importance of being unconventional, 

improvisational, and searching for and 

bringing ideas into our sessions from 

the worlds of art, drama, and literature, 

which are rich sources for inspiration, 

imagination, improvisation, and 

creative solutions. The latter resource 

areas take us far beyond the limitations 

of our choice therapy approaches 

and lend themselves well for finding 

creative ideas and constructively 

managing the dynamics we often face 

with our toughest couples and families. 

Things like uncertainty, ambiguity, 

unexpected crises, and wicked and 

intractable presenting problems that 

seem impervious to our change efforts 

(Selekman, 2013, 2010, 2005). 


Matthew D. 

Selekman, MSW, 

LCSW, is the 

director of Partners 

for Collaborative 

Solutions, an 

international family 

therapy training and 

consultation practice in Evanston, IL. He 

is the author of seven professional books 

and gives workshops throughout the 

world. 

References 

Minuchin, S. (1986). Four-day live supervision 

training in structural family therapy. Gestalt 

Integrated Family Therapy Institute, Chicago, IL. 

Selekman, M. D. (2010). Collaborative brief 

therapy with children. New York: Guilford. 

Selekman, M. D. (2005). Pathways to change: 

Brief therapy with difficult adolescents, 2nd 

ed. New York: Guilford. 

Selekman, M. D. & Beyebach, M. (2013). 

Changing self-destructive habits: Pathways 

to solutions with couples and families. New 

York: Routledge. 

Schon, D. A. (1983). The reflective practitioner: 

How professionals think in action. New York: Basic. 

don’t miss! 

Therapeutic Artistry: Finding 

Your Creative Edge with Your 

Most Difficult Couple and 

Family Practice Situations by 

Matthew D. Selekman, 

March 6-9, in Baton Rouge, LA. 

See page 37 for 

registration information. 

Over the years, I have been developing practice strategies for further cultivating my improvisational 

style as a therapist and ways to be more inventive for both myself, and the therapists I supervise and 

train to help them find their creative edge. Following are 19 practice strategies. 

1. Fertilize your brain by reading more science fiction, 

philosophy, detective mystery books, non-fiction 

biographies on famous artists, scientists, historic figures 

and events, and business books. 

2. Dust off and browse through your old Dr. Seuss books, 

look at cartoons in the newspaper and on TV, watch 

Comedy Central, Seinfeld, and Woody Allen movies. 

3. Go to jazz concerts of top players to experience 

improvisation at its best. 

4. Go to art museums and pay close attention to the artists 

who intrigue and inspire you the most 

5. Build mindfulness meditation and related practices into 

your daily regime. 

6. Infuse more rhythm into your sessions and into your 

daily regime by listening to different types of music, 

playing an instrument, dancing, engaging in artwork, or 

exercising. 

7. Daily, be on the look out for anomalies, meaningful 

coincidences, good luck events, and epiphanies to seize 

both in and out of sessions. 

8. View every problem with a beginner’s mind. 

9. Think and play with new ideas with the undying 

curiosity of a child. 

10. Think and experiment with opposites. 

11. View uncertainty and adversity as opportunities. 

12. What would be a song title or newspaper headline that 

best captures this challenging family? 

13. When faced with a challenging couple or family, hop into 

your imaginary helicopter to gain an aerial view to see what 

you may be missing. 

14. Imagine Rene Magritte, Dizzy Gillespie, and chef Bobby 

Flay visited you during your intersession break with this 

challenging family. What recommendations would each of 

them have for you to try out? 

15. Complete the statement with as many ideas as possible 

and pursue the ideas that you think have the best shot 

at working in your next session: “It would be really crazy 

if I…” 

16. What if your success were completely guaranteed with 

your toughest family; what would you try and pull off in 

today’s session? 

17. With a challenging couple, ask yourself, “How can I be 

even more incompetent with them?” Now, get to work! 

18. What if you woke up today with a severe case of amnesia 

and have completely forgotten your choice therapy 

approach with your clients. What would you do? How 

would you manage? What would you do next? 

19. If the Persian poet Rumi were a guest consultant for 

today’s session, what valuable words of wisdom would he 

offer you and your clients? 

Although this is not the definitive list of practice strategies for cultivating the creative use of self, 

my hope is that these ideas will inspire you to be more daring, inventive, and improvisational in your 

clinical work with challenging couples and families. 


hypnotherapy 

in Marriage and Family Therapy 

Gary Elkins, PhD 

Cassie Kendrick, PsyD 


Marriage and family therapists (MFTs) face the daunting 

task of effectively and efficiently addressing a myriad 

of issues that can affect the well-being of individuals 

and families. Further, within the current healthcare 

environment, there is a need for MFTs to provide brief 

and effective interventions that are also 

cost efficient. Hypnotherapy is one such brief, 

effective intervention that can be employed as a primary 

therapy or as an adjunct to more traditional marriage 

and family therapies. There is increasing evidence that 

hypnotherapy is an effective tool for many different 

problems. MFTs who are trained in hypnotherapy bring a 

broad range of skills that can expand the scope 

of practice of MFTs and their client 

base. Currently, many MFTs are interested in training in 

hypnotherapy and learning about its many applications. 


Hypnotherapy: Case Example 

Mary was a 56-year-old married 

woman who was referred by her family 

physician to an MFT due to increasing 

feelings of stress and anxiety. Mary 

reported that she had worked at her 

job as a real estate agent for the past 

eight years and that declining home 

sales the past two years had been 

especially stressful for her. During the 

initial interview she revealed she was 

having difficulty sleeping and felt 

tense much of the time. She indicated 

she was having hot flashes and night 

sweats since discontinuing hormone 

replacement therapy two years ago. 

In addition, she discussed that she 

tended to worry about her adult son and 

daughter, both married and living in 

another state. 

The MFT discussed with Mary that the 

use of hypnotherapy might be helpful 

in learning how to manage stress, 

sleep better, and that learning selfhypnosis 

could help reduce hot flashes. 

Mary’s questions about hypnotherapy 

were answered and she was told 

that hypnotherapy could be used in 

conjunction with therapy at each 

session. 

Mary continued for six sessions of 

hypnotherapy. To aide in planning her 

sessions, she completed a measure 

of her hypnotic abilities (Elkins 

Hypnotizability Scale [EHS]; Elkins, 

2013) that indicated she was in the 

average range. Her therapist completed 

the first hypnotic induction with 

suggestions for relaxation, increased 

control, and reduction of worry. The 

MFT also provided Mary with an audio 

recording of the session for her to listen 

to at bedtime to help reduce sleep 

latency. The next five sessions included 

a focus on reducing hot flashes. 

Hypnotic suggestions included mental 

imagery for “coolness and safety” and 

Mary was instructed in self-hypnosis. 

By the end of the sixth session, Mary 

reported she was sleeping much better 

and felt more relaxed. In addition, her 

hot flashes had markedly decreased and 

she was no longer having any difficulty 

with night sweats. She continued for 

six additional sessions with her MFT as 

her insight into the causes of her stress 

had increased and she continued to 

make changes to better cope with the 

everyday frustrations in her life. 

Historical Foundations 

The beginnings of modern hypnosis 

are credited to the work of Anton 

Mesmer, a late 18th century Viennese 

physician. Mesmer’s theory of “animal 

magnetism” was based upon his belief 

that the forces acting upon the body 

could be manipulated through the use 

of suggestion and magnets. Although 

Mesmer’s methods were eventually 

discredited, his work would influence 

the field for years to come. Even today, 

his practices are still sometimes referred 

to as “Mesmerism.” 

In 1841, Scottish physician James Braid 

first used the term hypnosis (derived 

from the Greek word “hypnos,” meaning 

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MFTs who are trained in 

hypnotherapy bring a broad range of 

skills that can expand the scope of 

practice of MFTs and their client base. 

Problems 

Treated with 

Hypnotherapy 

sleep) to describe the trance state his 

patients achieved using eye fixation. 

Hypnosis involves focused attention and 

relaxation, and a patient experiencing a 

trance state may appear as if he or she 

is asleep. Researchers now understand 

that hypnosis and sleep are very 

different (Crasilneck & Hall, 1985). 

Toward the end of the 19th century, 

Sigmund Freud used hypnosis to treat 

hysteria prior to developing his theory 

of psychoanalysis, and by the mid- 

20th century, professional societies, 

such as the Society for Clinical and 

Experimental Hypnosis (1949) and the 

American Society of Clinical Hypnosis 

(1957), were established. In subsequent 

years, research has validated the clinical 

application of hypnotherapy and its use 

in psychotherapy and healthcare. 

Empirical Research 

Empirical evidence regarding the 

effectiveness of hypnotherapy is 

accumulating (Elkins, 2013). Although 

early research relied heavily on case 

studies, more recent research has 

demonstrated the utility of clinical 

hypnosis for a myriad of conditions 

through the conduct of randomized 

clinical trials. Areas that may be 

of particular interest for MFTs may 

include stress, chronic and acute pain, 

headaches, anxiety, women’s health, 

and issues related to chronic illness in 

children. 

Pain Management 

Hypnotherapy can be particularly 

powerful for the person suffering 

from acute or chronic pain (Elkins, 

2013). When applied to pain, a 

hypnotic intervention generally 

involves suggestions for relaxation, 

perceptual changes, better coping, and 

continued pain management posttreatment. 

Hypnotherapy has been 

shown to effectively address back pain, 

fibromyalgia, headaches, and procedural 

pain, as well as pain associated with 

cancer, and joint disorders (Elkins, 

Johnson, & Fisher, 2012). 

Sexual Dysfunction 

Hypnotherapy as a primary or 

adjunctive therapy can be effective in 

addressing issues of sexual dysfunction, 

such as erectile and orgasmic 

dysfunction and low sex drive (Berner& 

Günzler, 2012). For example, in one 

study, hypnosis resulted in 80 percent 

improvement in men with non-organic 

erectile dysfunction (Aydin, Odabas, 

Ercan, Kara, & Agargün, 1996). 

Hot Flashes 

There is a growing body of research 

supporting the use of hypnotherapy in 

the treatment of hot flashes and related 

symptoms. Hypnosis has been shown 

to reduce the frequency and severity of 

hot flashes and also to improve related 

symptoms such as quality of life and 

interference in daily functioning among 

postmenopausal women. For example, 

in a large randomized clinical trial, hot 

flash scores (a measure of frequency 

and severity) were reduced on average 

by 80.32 percent following a five-week 

hypnotic intervention (Elkins, Fisher, 

Johnson, Carpenter, & Keith, 2013). In 

addition, hypnosis has been shown to 

reduce the frequency and severity of hot 

flashes among breast cancer survivors 

(Elkins, Marcus, Stearns, Perfect, Rajab, 

Ruud, & Keith, 2008). 

Anger Management 

Anxiety Management 

Asthma 

Adjunct Burn Therapy 

Acute and Chronic Pain 

Concentration 

Conversion Disorder 

Dissociative Disorder 

Drug Abuse 

Grieving 

Habit Control 

Hair Pulling (Trichotillomania) 

Insomnia 

Hot Flashes (Post-Menopause 

and Cancer) 

Irritable Bowel Syndrome 

Labor and Delivery Pain 

Memory Work 

Migraine and Other Headaches 

Nausea Associated with 

Chemotherapy 

Neurodermatitis 

Phobias 

Poor Self-Esteem 

Post-Traumatic Stress Disorder 

Psychogenic Impotency 

Psychogenic Seizures 

Sexual Problems 

Stuttering 

Tension Headaches

don’t miss! 

Hypnotherapy for Pain, 

Anxiety, and Habits: The 

Basics andBeyond by Gary 

R. Elkins, March 6-9, in 

Baton Rouge, LA. 



Post-traumatic Stress Disorder 

Hypnosis is also well suited for use as 

an adjunct to cognitive based therapies 

in the treatment of posttraumatic 

stress disorder. Early on in treatment, 

hypnosis can be utilized to augment 

self-soothing and affect regulation skills 

and to decrease states of hyper-arousal 

(Lynn, Malakataris, Condon, Maxwell, & 

Cleere, 2012). In addition, hypnotherapy 

can be useful in improving sleep in 

persons suffering from PTSD. For 

example, at least one trial demonstrated 

that hypnotherapy resulted in improved 

sleep quality and less nighttime 

awakening (Abramowitz, Barak, Ben- 

Avi, & Knobler, 2008). 

Sleep Disorders 

Integration of hypnotherapy into a 

larger treatment strategy can also 

bring relief to persons suffering with 

insomnia. Hypnosis intervention 

can shorten the time to fall asleep 

in persons who suffer from chronic 

insomnia (Elkins, 1997). Patients who 

receive hypnotherapy generally fare as 

well as those taking pharmaceuticals in 

the short term, and better in the long 

term (greater than eight weeks). 

Hypnotherapy with Children 

Children can generally use imagery and 

suspend critical judgment with ease. 

As such, children are well suited to 

utilize hypnosis to promote therapeutic 

outcomes. When using hypnosis 

with children, therapists should be 

careful to provide interventions that 

are developmentally appropriate and 

suitable to the child’s personal interests. 

Applications of hypnotherapy with 

children are numerous and include 

psychological and habit disorders, pain 

control, enuresis, learning and attention 

disorders, and grief and bereavement 

(Wester & Sugarman, 2007). 

Contraindications 

Hypnosis is generally considered a 

safe, effective treatment with few, if 

any, negative side effects. However, 

hypnotherapy may not be indicated 

for persons with borderline personality 

disorder, schizophrenia, and some 

dissociative disorders. In such cases, 

therapists should be competent in the 

treatments of these disorders and in 

hypnotherapy prior to proceeding. 

Training 

MFTs interested in incorporating 

hypnotherapy into their practice should 

acquire appropriate postgraduate 

training and supervision. Two levels 

of certification (Elkins & Hammond, 

1998) are offered through the American 

Society of Clinical Hypnosis (ASCH). 

These certifications require appropriate 

and approved beginning, intermediate, 

and advanced training, as well as 

documented experience using hypnosis 

in professional practice. 

Gary Elkins, PhD, 

is the director of the 

Mind-Body Medicine 

Research Laboratory 

and director of the 

PsyD program in 

clinical psychology 

at Baylor University. 

He is the president-elect of the Society 

for Psychological Hypnosis and associate 

editor of the International Journal of 

Clinical and Experimental Hypnosis. 

Cassie Kendrick, 

PsyD, is a postdoctoral 

Fellow in the 

Mind-Body Medicine 

Research Laboratory 

and adjunct lecturer 

at Baylor University. 

References 

Abramowitz, E. G., Barak, Y., Ben-Avi, I., & 

Knobler, H. Y. (2008). Hypnotherapy in the 

treatment of chronic combat-related PTSD 

patients suffering from insomnia: A randomized, 

zolpidem-controlled clinical trial. International 

Journal of Clinical and Experimental Hypnosis, 

56(3), 270-280. 

Aydin, S., Odabas, Ö., Ercan, M., Kara, H., & 

Agargün, M. Y. (1996). Efficacy of testosterone, 

trazodone and hypnotic suggestion in 

the treatment of non-organic male sexual 

dysfunction. British Journal of Urology, 77(2), 

256-260. 

Berner, M., & Günzler, C. (2012). Efficacy of 

psychosocial interventions in men and women 

with sexual dysfunctions: A systematic review 

of controlled clinical trials. Journal of Sexual 

Medicine, 9(12), 3089-3107. 

Crasilneck, H. B. & Hall, J. A. (1985) Clinical 

hypnosis: Principles and applications (2nd ed.) 

New York: Grune & Stratton. 

Elkins, G. (2013). Hypnotic relaxation therapy: 

Principles and applications. Springer Publishing 

Company. 

Elkins, G. R., Fisher, W. I., Johnson, A. K., 

Carpenter, J. S., & Keith, T. Z. (2013). Clinical 

hypnosis in the treatment of postmenopausal 

hot flashes: A randomized controlled trial. 

Menopause, 20(3), 291-298. 

Elkins, G.R., & Hammond, D.C. (1998). Standards 

of training in clinical hypnosis: Preparing 

professionals for the 21st century. American 

Journal of Clinical Hypnosis, 41(1), 55-64. 

Elkins, G., Johnson, A., & Fisher, W. (2012). 

Cognitive hypnotherapy for pain management. 

American Journal of Clinical Hypnosis 54(4), 

294-310. PMID: 22655332. 

Elkins, G., Marcus, J., Stearns, V., Perfect, M., 

Rajab, M. H., Ruud, C., Palamara, L., & Keith, 

T. (2008). Randomized trial of a hypnosis 

intervention for treatment of hot flashes among 

breast cancer survivors. Journal of Clinical 

Oncology, 26(31), 5022-5026. 

Elkins, G. R. (1997) Consulting about insomnia: 

Hypnotherapy, sleep hygiene, and stimuluscontrol 

instructions. In Current thinking and 

research in brief therapy, Matthews, W. J. & 

Edgette, J. H. (Eds.) New York: Brunner/Mazel. 

Lynn, S. J., Malakataris, A., Condon, L., Maxwell, 

R., & Cleere, C. (2012). Post-traumatic stress 

disorder: Cognitive hypnotherapy, mindfulness, 

and acceptance-based treatment approaches. 

American Journal of Clinical Hypnosis, 54(4), 

311-330. 

Wester, W. C., & Sugarman, L. I. (2007). 

Therapeutic hypnosis with children and 

adolescents. Bethel, CT: Crown House 

Publishing. 


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Northcentral's School of Marriage and Family Sciences offers predominantly 

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culturally sensitive marriage and family therapist. Our COAMFTEaccredited 

MA program focuses on foundational training to prepare you 

for MFT licensure in most states. The PhD program offers advanced 

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BEHAVIORAL ADDICTIONS: 

Turning 

It Around 

Meri L. Shadley, PhD 


Substance abuse, compulsive gambling, 

sexual compulsivity, and persistent 

shopping, exercising, or internet gaming 

all have a common thread—they are 

all behaviors that can interfere with an 

individual’s healthy living and have intense 

repercussions on the individual’s family. 

Many are left devastated and dramatically 

altered by the downward spiral of 

addictive behaviors. Long-held negative 

engagement patterns may continue 

to live insidiously within relationships 

long after the addiction leaves. Most 

importantly, children for generations 

to come may struggle with their own 

addictive issues if these patterns go 

unchecked. 


Many addictive behaviors start out 

as socially acceptable activities that 

enhance interpersonal interaction 

and increase self-esteem. Alcohol may 

initially provide social ease, and the 

excitement experienced from a boss’s 

accolades can increase a person’s 

sense of confidence. It’s not hard to 

see how the endorphin high received 

from a good workout, a win at poker, 

or the flirtations of a potential 

partner might increase the desire to 

return again to that specific activity. 

Unfortunately, the reinforcement 

received from these triumphs can 

deceive everyone and hide a growing 

problem. Gone unchecked, behavioral 

addictions can wreak havoc in family 

life. 

So how is one to know when the pursuit 

of pleasure and success has crossed 

over into a dangerous habit? Addiction 

counselors suggest that the defining 

variable is when the behavior begins 

to interfere with a person meeting 

their daily responsibilities. While this 

is a good monitor, family relationships 

may actually begin to deteriorate long 

before an addiction is detected. A 

suspicious family member may be the 

first to uncover the devastating effects 

of a “hidden” addiction. Since family 

therapists are often on the front line of 

this discovery, their alertness to family 

“dis-ease” may assist in interrupting the 

development of a behavioral addiction. 

A large number of addiction counselors 

conceptualize addiction problems 

don’t miss! 

Dynamics of Addiction 

Treatment and Recovery by 

Meri L. Shadley, March 6-9, 

in Baton Rouge, LA. 



as requiring individually focused 

treatment approaches. Yet, while 

the individual in recovery addresses 

triggers, builds new skills, and faces 

emotional residue, other family 

members face their own demons. Many 

experience a sense of powerlessness 

and betrayal when confronting the 

addiction, thus, they are left with a 

loss of hope, trust, and safety. Along 

with these emotional scars, when 

addictive behaviors have controlled 

family life many common patterns of 

dysfunction develop. 

Two SAMSHA documents (2004, 

2013) detail some of the problematic 

dynamics as: many families 

lack effective parenting, family 

management and communication skills; 

addicted parents frequently don’t 

provide structure or discipline, yet 

expect children to be competent and 

self-disciplined; family disorganization 

may create high conflict and low family 

cohesion; and, violence or disengaged 

attachment patterns may develop 

as a response to the family disorder. 

Finally, it is known that the increased 

emotional isolation and family 

dysfunction frequently make members 

more vulnerable to mood disorders and 

other mental health issues (Giglio & 

Kaufman, 1990). 

Whether at the stage of discovery or in 

later stage recovery, family treatment 

is considered a “best practice” for 

healing the many wounds resulting 

from addictions. In fact, “family 

therapy is the treatment with the 

strongest evidence of comparative 

effectiveness” (Tanner-Smith et al., 

2013, p. 145). Armed with clinical 

skills, family therapists who understand 

the patterns found around addiction 

and are willing to face their own beliefs 

and experiences about addiction can 

be valuable allies to recovery. Their 

ability to look at the individual within 

the family context and their training 

to treat both systems and individuals 

allows them to focus on recovery and 

prevention at the same time. 

So how is one to know when the pursuit of 

pleasure and success has crossed over into a 

dangerous habit? 

Understanding and Treating 

Addiction in the Family 

A simple structure is critical to help 

family clinicians wed the individual 

focus of addiction treatment and the 

systemic focus of family therapy. Since 

the late 1970s, I have utilized the 

SPATS framework (DeWitt & Shadley, 

1981/2007) to provide this structure. 

SPATS, an acronym for the five critical 

aspects of the therapeutic encounter 

(Structure, Process, Assessment, 

Techniques, and Self), provides the 

backdrop for integrating addiction 

and family treatment. Utilizing 

SPATS, therapists are able to detail 

information about the client system, 

to assess the potential for change or 

relapse, to conceptualize appropriate 

interventions, and to address aspects of 

self that could assist or interfere in the 

therapeutic encounter. 

SPATS advocates that the therapist 

first review the family’s Structure 

and Process (i.e., the roles, rules, 

boundaries, homeostasis, patterns 

of communication, and conflict 

resolution style) including looking 

at the sociocultural, family history, 

and individual factors that might be 

influencing the addictive behaviors. 

Second, assessing the changing 

landscape during treatment is critical 

to ongoing recovery, thus, SPATS asks 

therapists to determine their clients’ 


overt and covert goals, as well as 

their own process and outcome goals 

frequently. Looking at goals through 

the therapist interface issues of pace, 

ground rules, system buy-in, and role 

helps direct necessary fluctuations in 

the treatment process. Evaluating these 

factors through an assessment of the 

family’s growth resources and potential 

bear traps provides an ongoing analysis 

of the family’s readiness for change and 

guides the intervention plan. 

Undoubtedly, the family is fertile 

ground for multiple generations 

of addiction problems. Ultimately, 

clinicians must decide on approaches 

that both protect the individual’s 

recovery and help change dynamics 

that hinder immediate and longterm 

healing. The Technique section 

of SPATS asks the therapist to 

conceptualize their interventions from 

the frame of 1) their own competency, 

familiarity, and training with certain 

techniques and approaches; 2) how 

much the techniques would be 

contrasting or complementing the 

family system; and 3) the level of 

family distress (called vital signs). 

Utilizing Selye’s research about the 

body’s general adaptation to stress 

(1950) it is critical that clinicians 

choose techniques that move the 

family forward without creating 

so much additional stress that it 

endangers relapse or system collapse. 

As the therapist begins to see the 

family, they must also remember how 

their personal lens may affect their 

views. The scaffolding of SPATS deems 

the Self as the core to which all other 

aspects are determined. It establishes 

the therapist’s self as an organizing 

hub for understanding their clients, 

their own skills and effective treatment 

activities. Keeping an eye on one’s own 

thoughts, attitudes, opinions, feelings, 

and reactions affirms the importance of 

self-awareness. Such mindfulness builds 

therapeutic mastery. As the therapist 

is more effective in their “use of self” 

it can be gracefully employed for the 

benefit of one’s clients. 

A recent posting on Facebook showed 

a sign stating, “I was addicted to 

the hokey pokey but I turned myself 

around.” While humorous, this 

statement also speaks to the general 

acceptance that behavioral addictions 

exist and to the belief that change is 

possible. Unearthing and redesigning 

dysfunctional relationship dynamics 

gives family therapists an important 

role in supporting recovery. And, that’s 

what it’s all about! 

Meri L. Shadley, 

PhD, LMFT, LCADC, 

LCS, is associate 

professor / academic 

coordinator at Center 

for the Application 

of Substance Abuse 

Technologies (CASAT) 

and project director at Nevada’s Recovery 

& Prevention Community (NRAP). She has 

a clinical practice in Reno, NV. Shadley is 

a Clinical Fellow of AAMFT. 

References 

DeWitt, W. M. & Shadley, M. L. (1981). A 

kaleidoscope of family systems: A training 

manual. (Rev. ed. 2007). Reno, NV: Self 

published. 

Giglio, J. J., & Kaufman E. (1990). The 

relationship between child and adult 

psychopathology in children of alcoholics. 

International Journal of the Addictions, 25(3), 

263-290. 

Johnson, J. L., & Leff M. (1999). Children of 

substance abusers: Overview of research 

findings. Pediatrics, 103(5 Pt. 2), 1085–1099. 

Selye, H. (1950). Stress and the general 

adaptation syndrome. British Medical Journal 

1(4667), 1383-1392. 

Substance Abuse and Mental Health Services 

Administration. (2013). Results from the 2012 

national survey on drug use and health: 

Summary of national findings, NSDUH Series 

H-46, HHS Publication No. (SMA) 13-4795. 

Rockville, MD: SAMHSA. 

Substance Abuse and Mental Health Services 

Administration. (2004). Treatment improvement 

protocol (TIP) series, No. 39. Rockville, MD: 

SAMHSA. Retrieved from http://www.ncbi.nlm. 

nih.gov/books/NBK64258/. 

Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. 

W. (2013). The comparative effectiveness of 

outpatient treatment for adolescent substance 

abuse: A meta-analysis. Journal of Substance 

Abuse Treatment, 44, 145-158. 

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The AAMFT Institutes for 

Advanced Clinical Training 

March 6 – 9, 2014* • Baton Rouge, Louisiana 

Earn 20 or 30 hours of continuing education credit with 

the most advanced marriage and family therapy training 

available! Register online at www.aamft.org/institutes. 

This “can’t miss” training for the advanced MFT is offering you 

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our most popular topics. Register by February 1, 2014 to secure 

your seat at our lowest rates. 

*The Approved Supervisor Refresher Course will take place on March 5, 2014. 


Featured Presenters and Workshops 

Hypnotherapy for Pain, 

Anxiety, and Habits: The 

Basics and Beyond 

Gary R. Elkins, PhD 

March 6 - 9, 8:00 a.m. - 1:00 p.m. 

In the ever-changing mental health 

environment, many MFTs are 

seeking ways of enhancing their practices with new clinical 

skills. Taught by one of the most respected leaders in the 

field of clinical hypnosis, this course will focus on clinical 

hypnotherapy methods, pain and stress management, and 

treatment of various clinical problems. Attendees will learn the 

essentials of clinical hypnosis, methods of hypnotic induction, 

the effective use of hypnotherapy as a mind-body intervention 

and a wide range of applications in clinical practice. 

Dynamics of Addiction 

Treatment and Recovery 

Meri L. Shadley, PhD, 

MFT-S, LCADC-S 

March 6 - 9, 8:00 a.m. - 1:00 p.m. 

Alcoholism, drug abuse, compulsive 

gambling, and other behavioral 

disorders such as sexual compulsivity, persistent shopping, 

and internet obsession have a common thread — they all 

not only interfere with an individual’s healthy living, but 

they impact the life of all family members. Many families 

are left devastated and dramatically altered. Marriage and 

family therapists bring a perspective uniquely different 

than the typical substance abuse treatment orientation. 

In an effort to wed our systems views with the more 

manualized protocols presently utilized, this course will 

introduce a systemic framework. Attendees will receive 

an overview of addiction specific theories, techniques, 

and strategies and receive an opportunity to relate this 

information to families suffering from the increasing 

problems of disordered gambling, internet addiction, and 

other behavioral compulsions. 

Additional institutes to be 

added! Visit www.aamft.org/ 

institutes for more information 

or to register! 

Therapeutic Artistry: Finding 

Your Creative Edge with Your 

Most Difficult Couple and 

Family Practice Situations 

Matthew D. Selekman, MSW, LCSW 

March 6 - 9, 8:00 a.m. - 1:00 p.m. 

At times in our professional careers, 

all of us have been faced with clinical situations in which we 

were intimidated by or experienced therapeutic paralysis 

in reaction to particular clients’ provocative and perplexing 

presenting problems and extensive treatment histories, 

families with multiple symptom-bearing members carrying 

serious DSM diagnoses, and couples and families who 

seem to thrive on one crisis to the next. In this hands-on, 

practice-oriented workshop, attendees will learn several 

effective ways therapists can tap the full range of their inner 

resources and creative selves for getting unstuck and being 

the catalysts for therapeutic change with complex and 

difficult client practice situations. 

The Fundamentals of MFT 

Supervision 

Toni Zimmerman, PhD 

March 5: 4:30 - 7:30 p.m. 

March 6 - 9: 8:00 a.m. - noon, 

1:00 - 5:00 p.m. 

This 30-hour intensive program is 

designed to fulfill the complete course requirement for the 

AAMFT Approved Supervisor designation and satisfies 

the supervisory training requirements for many state laws. 

Approved Supervisor Refresher (March 5, 2014) 

Jerry Gale, PhD 

NOTE: This course is offered before the institutes begin. 

It provides 5 hours of continuing education credit. 

To maintain the highest quality supervisors in the field, 

AAMFT requires that Approved Supervisors take a 

refresher course prior to the renewal of their designation. 

This course is designed to meet that requirement and to 

keep participants up to date on the practice of clinical 

supervision. This course may be used to qualify for the 

Approved Supervisor designation by those who took the 

full course more than five years ago.

The AAMFT Institutes for Advanced Clinical Training 

March 5 – 9, 2014 • Baton Rouge, Louisiana 

Hotel and Location 

The 2014 AAMFT Institutes for 

Advanced Clinical Training provide 

the highest level of intensive 

education available to MFTs in one 

of America’s fastest growing cities! 

Featuring legendary Southern 

cuisine and rich in history and 

landscape, Baton Rouge is the ideal 

location to convey our institutes’ 

work hard, play hard theme. 

For more information on Baton Rouge, visit 

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The 2014 institutes will be held at the exquisite Hilton 

Baton Rouge Capitol Center situated on the banks of the 

Mississippi River and within walking distance from all of 

the historic downtown attractions. 

To secure your discounted room rate of $125/night plus 

taxes, call registration directly at 1-800-955-6962 and give 

the code AAM or ask for the American Association for 

Marriage and Family Therapy room block. 

Travel Information 

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legal & 

ethical issues 

Gifts, “Thank Yous,” and the 

“Why I Do This” Box Part II 

Lisa Rene Reynolds, PhD 

There are several other issues that clinicians should 

reflect upon before deciding on a personal policy on 

gift acceptance. Keeping the aforementioned organizational 

guidelines in mind (covered in part I of this series), 

consider the following situations. 

I once saw a very affluent, successful surgeon for marital 

sessions several years ago. This was a self-pay client, and 

after several sessions that he deemed to be “extremely 

helpful,” he wrote out the usual $100 check for $600. I 

noticed the inflated amount and thought maybe he had 

accidentally written a “6” instead of a “1.” I told him he 

made out the check for a much higher amount than he 

should have. He responded that it was well deserved for 

good service. He reported he had been married before and 

done counseling in those unions, but it had not been as 

effective as this time around. I was very uncomfortable 

and flabbergasted. After trying repeatedly to return his 

check and having him refuse, we agreed that I would 

“credit” his account with the extra for future sessions. 

When we terminated, I refunded the remaining $100 

overpay with a bank check and seemingly, he accepted 

our “agreement.” 

First, examine the client’s motive in giving the gift. 

Is it coming purely from a place of gratitude, or is the 

client expecting something in return from the clinician? 

For example, does a wife’s gifts to the therapist foretell 

her interest in swaying the therapist’s allegiance in 

her direction during difficult marital therapy sessions, 

or before her husband’s attorney requests a letter 

documenting the progress in therapy? 

Next, deliberate on mental health issues and how they 

may play into the choice for a client to gift the clinician. 

For some clients, one of the key components of therapy 

relates to understanding personal boundaries and 

implementing healthier ones into their relationships. 

The therapeutic relationship can often be the safest and 

most productive place to do this. Think about whether a 

gift teeters on an inappropriate boundary. For instance, a 

client who wants to offer her clinician free massages (that 

would entail being partially naked and incorporating a 

much more intimate kind of touch than what is generally 

experienced in the therapeutic relationship). 

Lastly, if we reflect on the concept of transference in 

the therapeutic relationship, gift giving/accepting may 

play a role here as well. Transference is defined as, “the 

redirection of feelings and desires and especially of 

those unconsciously retained from childhood toward a 

new object (as a psychoanalyst conducting therapy).” 

Transference, and countertransference (the clinician’s 

reaction to the client’s transference) are important parts 

of the therapeutic relationship. 

So, for example, let’s say the clinician who is offered a 

free haircut from her client brings along her two unruly 

young children to the appointment. As they disobey her, 

she becomes increasingly impatient and gets angry with 

them. The client sees the clinician in a new light now—in 

the role as parent. And perhaps the clinician’s parenting 

style triggers memories of the client’s own tumultuous 

relationship with his or her mother, and thus the client 

begins to judge the clinician unconsciously. This could 

potentially taint, and ultimately harm, the therapeutic 

relationship. 

Unfortunately, not every therapist has the clear vision, 

ability to carefully examine dynamics in the therapeutic 

relationship, and good judgment and conscience to 

navigate these (often tricky) situations with clients. For 

this reason, clinicians should accept gifts only after there 

is an adequate amount of ethical exploration, and after 

ensuring that the motivation for accepting the offering 

is in the best interests of the clients who offer them. 

Especially in private practice where one can feel very 

unsupported and isolated, it is important for therapists to 

discuss these situations with other therapists. After all, 

we can’t take ourselves out of the clinician role in order to 

view the situation without bias. Colleagues can help us to 

see what may be hidden in the complicated layers of the 

therapeutic relationship. 


Our work and dedication 

is not for nothing; there is 

no greater thank you than 

when we get to see the 

loving fruits of our efforts. 

Flash forward. I pull out some 

stationary from my desk and write the 

following to Chrissy: 

I am touched by your kind words and 

generous gift, but I am returning this 

card to you for several reasons. My 

professional association frowns upon 

the practice of accepting magnanimous 

gifts. But more importantly, I don’t 

need a gift as a thank you from you— 

your gratitude is demonstrated in your 

thoughtful gesture and words. You have 

worked hard this year at taking your 

life back and in searching for happiness 

again. I am so glad for you and it’s 

been an honor to accompany you on 

your journey. So, go buy yourself 

something with this gift card that you 

would never treat yourself to, and enjoy 

it—you deserve it! 

Fondly, Lisa 

I slip the gift card inside the envelope 

with the note, and ponder the art 

of the thank you. Yes, a gift card is 

useful, but if I’m honest, the warmand-fuzzy 

kind of gratefulness feels a 

lot better and lasts longer. 

When I return home, the experience 

prompts me to go visit the “Why I Do 

This” box that sits on a shelf in the 

back of my closet, collecting dust. I 

only take it out once a year, or maybe 

twice if I’ve had a particularly stressful 

work year. 

I yank the top off the pretty floral box 

and pull out a small handful of notes 

and cards from inside. Although I have 

been offered, and have accepted, only 

a few gifts from clients throughout my 

many years in practice, I have saved 

every single written thank you I have 

ever received. For it’s these cards and 

notes, and all the genuineness they 

contain, that reminds me why I chose 

this career. 

I find one of my favorites—a photo 

of a mom, dad, big brother, and a 

newborn baby, taken in a hospital 

room right after the mom’s delivery. A 

simple note scrawled on the back says 

it all—If we hadn’t met you, trusted 

you, and worked with you, there would 

be no intact family, nor would there be 

this beautiful moment of welcoming a 

new addition. From the bottom of our 

hearts, thank you. I still get choked up 

when I read this one. 

So, many times, we work hard and 

try our best, and often, we never 

know what becomes of those people 

whose lives we try to help improve. 

Some clients disappear from treatment 

unexpectedly, and others terminate 

when they are functioning better. 

Often, there is no further contact with 

the very people, our clients, who have 

shared with us their most intimate 

and vulnerable sides. Caught up in 

insurance billing snafus, countless 

unpaid phone calls for coordination 

of client care, and scheduling/ 

rescheduling headaches, we may forget 

why we do this work. Perhaps the 

greatest gift is when we can know that 

our work and dedication is not for 

nothing; there is no greater thank you 

than when we get to see the loving 

fruits of our efforts. 

Lisa Rene Reynolds, 

PhD, is a licensed 

marriage and 

family therapist in 

private practice in 

Connecticut. She 

is a Clinical Fellow 

of the AAMFT, and 

an adjunct professor in the psychology 

department of Western Connecticut 

State University. Reynolds is the author 

of several non-fiction books, including 

Parenting Through Divorce: Helping 

Your Kids Thrive During and After the 

Split. 


first person 

Sally Sells Sea Shells by the Seashore 

Merriam Sarcia Saunders, MS 

am in the kitchen. When I think of my family 

I interacting, this is where we are. Memories of us all 

together are few and far between. Partly because access 

to the 40+ year-old scenes of my youth is limited. But 

mostly because we rarely did anything together, outside of 

that kitchen. There was the business trip to Disneyworld 

we were once invited to, the family trip with friends to 

Lake George, and the Sunday dinners at Auntie Rose’s— 

with the entire extended Sicilian family to muddle to 

interaction. Other than that, we stayed home. Because if 

we were home, Dad had easy access to his mistress, The 

Bottle. 

My tall, striking, blond-haired, green-eyed Norwegian 

mother is standing in front of the electric stove—her 

command post—sautéing sliced zucchini that Dad grew 

in the garden. He will readily tell you that they grew 

so well because he mixed manure in the soil. And I will 

recoil in conflict, because at the same time that I think 

he is the smartest man alive and oh-so-clever for knowing 

to put manure in the soil, I really, really wish he would 

stop talking about cow dung. But Dad isn’t in this picture 

yet—he is on his way home from work. For now, it is our 

steadfast triangle, Mom, my brother JJ and I. 

We entertain her as she cooks. We are good at entertaining 

and she is a master at the stove. She throws amazing 

dinner parties. Her house is kept meticulously clean 

despite her messy children. Her tennis game is tough 

to beat. She has lots of friends and her children are her 

world. She wonders, more often than she likes to admit, 

why she feels so empty. 

I rest my head against her shoulder from behind and sing 

BeeGees’ songs into her ear in an off-key, goofy falsetto. 

She laughs and waits for me to finish, even though she 

needs something from the fridge. We love to make her 

laugh. Her laughter lights up her beautiful face and 

radiates with love and support that we feel to our core. 

My brother, two years younger at 9, is a scrappy, skinny 

kid with a tousle of thick brown hair and large doe eyes. 

He shimmies himself up the doorway and lodges himself in 

at the top of the door frame, using only his leg strength 

from a pair of legs that hardly look as though they could 

support his weight. We marvel at his feat, no matter how 

many times we see him do it. 

I am neatly setting the table now, putting everything 

exactly in its place as my mother showed me years ago. I 

will do it perfectly, because I am a rule follower. I learned 

long ago that the easiest way to get praise was to do 

things perfectly, or at least very, very well. And I love 

praise. Praise of any kind was an anchor in the chaotic, 

vacillating world of my alcoholic family. But I get ahead of 

myself—he is still not home yet. 

“You have to help me, you know!” I yell over to my 

brother as he plays with the cat. “Mom! He’s not helping!” 

“JJ, help your sister,” she says, a soft lob in his direction 

that he won’t take seriously. He doesn’t come to help. He 

rarely does. And there will be no consequences, which 

frustrates me, as there seldom are for him. He doesn’t 

do his chores, his homework, stays up past his bedtime, 

doesn’t eat his vegetables and sneaks dessert. He hardly 

ever gets caught, and if he does, eludes punishment by 

wielding his doe-eyed charm. To this rule follower, his 

audacity both amazes and repels me. Just the thought of 

being naughty like him raises my anxiety. In the universe 

of good and bad, he is the yin to my yang. 

We hear the garage door open. Dad is home. There is a 

visible shift in Mom. Gone is the smile from her face, the 

light in her eye. Comedy hour is over. Dad walks into the 

kitchen and JJ runs up to hug him while I stay at the 

table. Like a stepford wife, Mom mechanically takes his 

briefcase and sets it down on the wooden highchair I used 

as a baby but that the cats now use as a scratching post. 

He walks to the fridge and pours himself a beer in a tiny 

juice glass. He returns to her at her command post as she 

cooks and pecks her on the cheek from behind. Is it my 

imagination, or do I see her stiffen? That is the extent of 

their affection. It is not until years later that I will notice 

the absence of physical touch. At this point, this is all I 

know and I suppose it to be normal. 

“How was your day?” This is our cue to exit until called 

to dinner, but we can still hear them from the den. Mom 

will recount her day and Dad will listen absentmindedly 


as he looks through the mail and refills 

his glass, again and again. At some 

point, she will say something that will 

cause him to offer some “constructive 

criticism” and off he’ll go. 

“Ah, jeez, Janet. You should have done 

it this, that or the other way!” he tells 

her, agitatedly. “Now such and such 

might happen.” Dad is a worrier. A big 

one. He is always thinking the worst 

will happen. When I show him the 

“A” I get on my test, he’ll say “Good 

work. Now don’t go showing that to 

Susan Henning because she will get 

jealous and probably start spreading 

rumors around to make everyone hate 

you.” He quickly goes to dark places, 

of which I could never conceive. He 

says it’s because he is Sicilian and, 

as an island culture, they always had 

to prepare for attack from all sides. I 

think it is because in his life he has 

seen enough tragedy to believe the 

worst is true. 

Mom calls us to dinner. Dad pours 

another beer. 

“I don’t know why you don’t use your 

head, Janet. You know you’re smarter 

than you give yourself credit for.” 

He thinks it is a compliment, but it 

is never quite received that way. As 

his surge continues, we notice Mom 

gradually withdraw. Is he right? Should 

she know better? None of us, including 

her, are sure. 

“What about you, JJ?” he asks my 

brother over dinner. “Did you get any 

‘A’s today like your sister?” Of course 

he did not, and so we enter the world 

where he is made to feel less than 

because he is not me. He is the screwup, 

the clown. Although I am a child, 

even I know this is wrong. I feel bad 

for him, but at the same time I crave 

the attention, the validation. 

Dad is emotionally disengaged. From 

him, pride is the most easily elicited 

emotion, if you can call it one, so it is 

the only one I target frequently. It is 

Dad is emotionally disengaged. From him, 

pride is the most easily elicited emotion, if 

you can call it one, so it is the only one I 

target frequently. 

an elusive target, and when I hit it, I 

feel somewhat cheapened, as if I have 

betrayed my triangular coalition with 

Mom and J. 

Dinner is over. I don’t remember 

Mom saying anything. I am sure she 

must have, but the fact that I don’t 

recall represents to me her emotional 

withdrawl during our interactions. 

“Time to practice your ‘s,’ Merriam,” 

commands Dad as he sets a chair in the 

middle of the kitchen, a single isolated 

chair in the spotlight for all to witness 

my humiliation. He thinks I have a 

lisp. That no one else, including me, 

seems to hear it does not matter. He 

hears it, so it must be there. 

He takes another drink of beer from his 

tiny juice glass. He replenishes it with 

the large, dark bottle of Black Label 

beer from the fridge. He supposes that 

because he drinks from a small glass, 

we think he isn’t drinking much at all. 

He has my brother and I fooled, for 


first person 

written. He watches PBS, listens to 

Gilbert & Sullivan operas, and speaks 

Sicilian. He reads Yule Gibner and 

knows which wild plants on our acre 

property are edible. We admire him. 

And also, we hate him. 

As the night progresses, he becomes 

angrier and more critical. My brother 

and I don’t understand why. What have 

we done to make him so mad? I need 

to practice that ‘s’ more; if only I had 

done it right. And JJ should stop his 

wisecracks. Maybe Mom cooked the 

zucchini too long. 

We all want to love him... 

We admire him. And also, 

we hate him. 

Oh well, it doesn’t matter anymore. 

He has fallen asleep during The Archie 

Bunker Show, in the exact spot as 

every night, as evidenced by the 

permanent stain on the green sofa from 

the Grecian formula in his hair. 

“Sally sells sea shells by the seashore, 

sally sells seashells by the seashore,” 

I repeat to myself as I go upstairs to 

brush my teeth. Maybe tomorrow I’ll 

get it right. 

now. Not Mom, though. She painfully 

notices each and every time he goes 

back to the fridge. 

“Now, repeat after me: Sally sells sea 

shells by the seashore.” I say it. 

“No, that’s not right. Hear how heavy 

your ‘s’ is?” 

I don’t hear it, because it isn’t there. 

But I tell him I do. 

“Ok, say it again. Sally sells sea shells 

by the seashore.” I say it, and the cycle 

repeats, to no avail. I can never say it 

the way he wants to hear it. His anger 

and frustration escalate and I cling 

frantically to the well of praise I had 

formerly filled. It is depleted quickly, 

and I feel lost at sea, where Sally sells 

her shells. 

It never dawns on my brother and me 

to look to Mom for any protection from 

the criticism and attacks. She is one 

of us, on our team of three. Thirteen 

years younger than Dad and only 20 

years older than me, she is caught 

in the middle. Raised by a clearly 

borderline father whom she despised, 

she looked to her husband, my father, 

to fill two roles for her. She deferred to 

him, as did we, and we never expected 

differently. 

But she knows he has a drinking 

problem. She knows that the reason he 

falls asleep on the sofa each night is 

not because he had a hard day at work. 

She just doesn’t know what to do about 

it, so she suffers in silence. She feels 

trapped, conflicted as we all do. 

We all want to love him. He is amazing. 

He is a CPA and vice president of his 

company. He reads voraciously about 

anything, so seems to know something 

about everything. He plays the ukulele 

and knows every dirty limerick ever 

Merriam Sarcia 

Saunders, MS, is 

a Clinical Fellow 

of the AAMFT, and 

a certified special 

education and 

divorce mediator. 

Her presentation 

topics include Motivational Interviewing 

in a Mediation Caucus, Strategic Family 

Therapy, ADHD in the Classroom and 

Helping Children Succeed through 

Failure. Saunders is in private practice in 

Marin, CA. 


perspectives 

Family, Roles, Rules, Rituals & Eating Disorders 

Alli Spotts-De Lazzer, MA 

As a practicing clinician, you may have already worked 

with people struggling with an eating disorder*. 

Statistics show that about one in 20 young women 

experience an eating disorder (Academy for Eating Disorders, 

2013), and USA Today reported that at least half a million 

American teenage girls have been afflicted with these 

illnesses (2013). Further, eating disorders in midlife and 

later-life adults, males, and teenage boys continue to 

be increasingly reported (Alpert, 2013; Bahadur, 2013; 

Sheridan, 2012). Clients of any race, ethnicity, culture, or 

gender can be affected by these serious and potentially lifethreatening 

disorders (National Institutes of Health, 2008). 

Historically, family has been suspected as the cause of an 

eating disorder. Parents or siblings of a sufferer may feel 

relieved to discover that research supports that family 

interactions do not “cause” a loved one’s eating disorder (Le 

Grange, Lock, Loeb & Nicholls, 2010). The eating disorder 

sufferer is likely genetically or biologically vulnerable to 

an eating disorder, and then other factors (environmental 

influences, traumatic events, etc.) trigger the disorder’s 

onset. Though genetics and brain scans are the focus of 

current studies, the family is still a point of intervention 

and potential change. 

“Children from families where fat is taboo, where dieting 

is a way of life, or where weight is a source of discussion 

are more prone to eating disorders than children from 

families with more positive attitudes toward food” (Herrin 

& Matsumoto, 2007, p. 162). In a qualitative study, 

eating disordered participants reported that they believed 

negative weight-focus in the home—comments, attitudes, 

or teasing—heightened their own body-criticism (Loth, 

Neumark-Sztainer, & Cross, 2009). Various research has 

recognized weight-critical comments and teasing as risk 

factors for eating disorder behaviors (Mazzeo & Bulik, 

2009). Assisting families in understanding aspects that risk 

engaging a biological predisposition to eating disorders can 

help them shift to more protective or healing environments. 

Clinicians generally recognize that a person’s observations 

and interpretations of family rules and messages can become 

core schema that warrant challenging and correcting in 

order to potentially ameliorate various mental disorders. 

Helping clients to work through and change dysfunctional 

thoughts, intentions, behaviors, and maladaptive beliefs 

related to the eating disorder is part of the treatment 

(American Psychiatric Association, 2006). Whether the 

person vulnerable to eating disorders is living with or apart 

from the family, addressing that familial environment can be 

beneficial in regard to both treatment and prevention. 

I am currently a Certified Eating Disorders Specialist and 

have been working with this population since my clinical 

training began. Prior, I volunteered in the field, and for 

various reasons, I have been exposed to eating disorders for 

most of my life. From these experiences, I have noticed that 

when families incorporate a focus on dieting and looks as 

a status quo, the person vulnerable to the eating disorder 

can interpret—which often becomes a legitimate cognitive 

distortion—that their value and acceptance by the family 

and in life are based upon appearance, looks, or thinness. 

For example, beliefs similar to the following can function 

on both conscious and unconscious levels: “If I’m not thin, 

then I’m not worthwhile,” or “If I’m not the best I can be 

physically, then I won’t be good enough . . . loved . . . 

approved of . . . accepted.” Obviously, these kinds of beliefs 

can add fuel to an eating disorder. 

“If children get rewarded only for ‘what they do’ as opposed 

to ‘who they are,’ these children may learn to depend solely 

on external rather than internal validation” (Costin, 2007, 

p. 193). External focus can communicate that a person’s 

worth is based on product (measurable productivity and 

appearance), which tends to align with eating disorder 

beliefs. I often notice that people vulnerable to eating 

disorders who are from families that place high value 

on accomplishments (e.g., excelling in school or work) 

and that seem to have not spent much time or focus on 

acknowledging family members’ process, feelings, or internal 

values can lack self-esteem and coping skills. According to 

Loth et al., “Many participants reported that symptoms of 

their eating disorder emerged initially to help them cope 

with feelings that seemed unmanageable” (2009, p. 148). 

Some families and clients may greatly benefit by learning 

effective coping skills, feeling-expressiveness, and processinstead-of-product 

languages. 

Though not seen as causal, I notice that family environment 

can influence a person’s eating disorder. For example, 


Family rituals—mealtimes, 

holidays, celebrations, rewards for 

accomplishments, punishments, 

etc.—tend to also communicate 

family rules and values. 

in childhood, one sufferer’s family 

repeatedly referred to her with size 

references and nicknames (e.g., “the 

tiny sister”). This sufferer grew to 

value her size as her main uniqueness 

within her family and in the world. 

Another sufferer who yearned for his 

athlete-father’s acceptance bonded 

with the father through exercise 

and strict food practices. Even after 

years of struggling with an eating 

disorder, this sufferer believed that 

without the shared food and exercise 

regiments, the father would no longer 

like or accept him. Another sufferer’s 

parents implicitly and explicitly 

communicated that attractive and 

“nice things” are a priority in life; this 

family also displayed affection through 

financial support and gift giving, 

not words. This sufferer made sense 

of these environmental influences 

by formulating the following way 

of thinking: personal, familial, and 

societal acceptance is gained through 

being an attractive and “nice ‘thing.’” 

Another sufferer who interpreted a 

similar message believed that she 

could never be “good enough” to 

match her parents’ standards. Feeling 

defeated, she became overweight by 

bingeing; her low self-esteem reflected 

the perceived family rule that only 

attractive, thin people are truly 

worthwhile in the world. Finally, a 

sufferer interpreted her parents’ spoken 

and unspoken message of “cover up” to 

mean that her body was to be ashamed 

of. After decades of eating disorders, 

she discovered that the meaning of 

the “cover up” message came from a 

parental intention of protection: they 

hoped to guard her preciousness from 

being seen as a sexual object. 

Family rituals—mealtimes, 

holidays, celebrations, rewards for 

accomplishments, punishments, etc.— 

tend to also communicate family rules 

(“If you don’t eat everything on the 

plate, the cook will be insulted”) 

and values (“We value not hurting 

others”—e.g., the cook’s feelings) that 

can impact a person who is vulnerable 

to an eating disorder. I invite you, 

the reader, to consider your family 

of origin’s rituals. What food or body 

messages were communicated? What 

are your family’s spoken or unspoken 

expectations of family members around 

food, body, diet and performance? Now, 

imagine that you are as sensitive as 

“canaries in a coal mine” (an analogy 

eating disorder expert Carolyn Costin 

[2012] used to describe the eating 

disorder population’s level of keen 

sensitivity). What messages might you 

have internalized about yourself and 

the world around you? 

Interpretations of messages within 

the family environment can grow 

to become beliefs that help anchor 

eating disorder ideation. Exploring the 

vulnerable person’s or the sufferer’s 

experience of family environment 

can create opportunities to challenge 

cognitive distortions and to work 

through complex beliefs that may 

collude with eating disorder-related 

schema. Keep in mind that some 

beliefs may remain unbending, 

especially when our overarching 


societal culture seems to consent to 

valuing perceived beauty or body-ideal 

(e.g., The U.S. weight loss market 

revenues exceeded 60 billion dollars 

in 2012 [PRWeb, 2013]). Additionally, 

due to the genetic component of 

eating disorders, generationally 

transmitted attitudes and behaviors 

may be covertly operating in the 

present. Various sources advise, when 

possible, including family in a person’s 

eating disorder treatment. Gillett and 

colleagues (2009) recommend involving 

a focus on family process rules in 

individual, family, and group therapies. 

Of interest and significance, family 

environment can also be the basis 

of eating disorder healing and 

prevention. Family Based Treatment 

(FBT), also referred to as “Maudsley,” 

is an evidenced-based, time-limited, 

outpatient treatment for adolescent 

anorexia with a high treatment 

success rate. FBT includes significant 

family involvement in the healing 

process. Various sources highlight that 

family environment can align with 

eating disorder prevention. Loth and 

colleagues (2009) captured sufferers’ 

perspectives: 

Eight themes emerged regarding 

recommendations for families to 

prevent the onset of eating disorders: 

(1) Enhance parental support; (2) 

Decrease weight and body talk; (3) 

Provide a supportive home food 

environment; (4) Model healthy eating 

habits and physical activity patterns; 

(5) Help your children build selfesteem 

beyond looks and physical 

appearance; (6) Encourage appropriate 

expression of feelings and use of 

coping mechanisms; (7) Increase your 

understanding of eating disorder signs 

and symptoms; and (8) Gain support 

in dealing appropriately with your own 

struggles (p. 146). 

With specialized training in eating 

disorders, clinicians can potentially 

help clients to safely explore their 

eating disorder-related ideation 

and to shift eating-disorder-ripe 

environments to more preventative or 

protective environments. The roles of 

the family environment in both the 

prevention and progression of eating 

disorders continue to warrant further 

examination in both in the therapy 

room and in research. 

*Note: This article references “eating 

disorders” (Anorexia Nervosa, Bulimia 

Nervosa, and Eating Disorders Not Otherwise 

Specified) prior to “Feeding and Eating 

Disorders” as classified in the DSM-5. 

Alli Spotts-De 

Lazzer, MA, 

licensed marriage 

and family therapist 

and Certified Eating 

Disorders Specialist, 

has a private practice 

in Los Angeles, CA. In 

addition to her clinical work, Spotts-De 

Lazzer presents on eating disorders and 

publishes on current topics in the field of 

psychotherapy in national publications. 

For more information about the author, 

visit www.TherapyHelps.Us. 

References 

Academy for Eating Disorders. (2013). Fast 

facts on eating disorders. Retrieved from 

http://www.aedweb.org/AM/Template. 

cfm?Section=Resources_for_the_ 

Press&Template=/CM/ContentDisplay. 

cfm&ContentID=3564#.UqZiwpGnfwI. 

Alpert, E. (2013, June 13). Eating disorders 

plague teenage boys, too. Los Angeles 

Times. Retrieved from: http://articles.latimes. 

com/2013/jun/13/local/la-me-boys-eatingdisorders-20130614. 

American Psychiatric Association Work 

Group on Eating Disorders. (2006). Practice 

guideline for the treatment of patients with 

eating disorders third edition. Retrieved from 

http://psychiatryonline.org/content.aspx?boo 

kid=28&sectionid=1671334. 

Bahadur, N. (2013, July 26). What you need 

to know about men and eating disorders. 

Huffington Post. Retrieved from http:// 

www.huffingtonpost.com/2013/07/25/ 

men-eating-disorders-things-you-shouldknow_n_3625164.html. 

Costin, C. (2007). The eating disorder 

sourcebook. (3rd ed.). New York: McGraw- 

Hill. 

Costin, C. (2012). Canaries in a coal mine: 

The collateral damage from our culture of 

thinness [Video]. Retrieved from http://www. 

youtube.com/watch?v=g1QN04L0eMc. 

Eating disorders hit more than half million 

teens. (2011, March 7). USA Today. Retrieved 

from http://usatoday30.usatoday.com/news/ 

health/wellness/teen-ya/story/2011/03/ 

Eating-disorders-hit-more-than-half-millionteens/44608910/1. 

Gillett, K. S., Harper, J. M., Larson, J. H., 

Berrett, M. E., & Hardman, R. K. (2009). 

Implicit family process rules in eatingdisordered 

and non-eating disordered 

families. Journal of Marital and Family 

Therapy, 35(2), 159-174. Doi: 10.1111/j.1752- 

0606.2009.00113.x. 

Herrin, M. & Matsumoto, N. (2007). The 

parent’s guide to eating disorders (2nd ed.). 

California: Gurze Books. 

Le Grange, D., Lock, J., Loeb, K., & Nicholls, 

D. (2010). Academy for eating disorders 

position paper: The role of the family in eating 

disorders. International Journal of Eating 

Disorders (43)1, 1-5. 

Loth, K. A., Neumark-Sztainer, D., & Cross, 

J. K. (2009). Informing family approaches to 

eating disorder prevention: Perspectives of 

those who have been there. International 

Journal of Eating Disorders 42(2), 146–152. 

Mazzeo, S., & Bulik, C. M. (2009). 

Environmental and genetic risk factors for 

eating disorders: What the clinician needs 

to know. Child and Adolescent Psychiatric 

Clinics of North America, 18(1), 67-82. doi: 

10.1016/j.chc.2008.07.003. 

National Institutes of Health. (2008, Spring). 

Understanding eating disorders. NIH Medline 

Plus 3(2), 17-19. Retrieved from http://www. 

nlm.nih.gov/medlineplus/magazine/issues/ 

spring08/articles/spring08pg17-19.html. 

PR Web. (April 16, 2013). Weight Loss Market 

in U.S. Up 1.7% to $61 Billion. Retrieved from 

http://www.prweb.com/releases/2013/4/ 

prweb10629316.htm. 

Sheridan, M. K., (2012xf, March 2). Eating 

disorders in middle age bring unique 

challenges, treatments. Huffington Post. 

Retrieved from http://www.huffingtonpost. 

com/2012/03/02/eating-disorders-middleage_n_1313791.html. 


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