Assignment: Relationship Between Qualitative Analysis and EBP

Client Advocacy in Marriage and Family Therapy:

A Qualitative Case Study

Diane R. Gehart Brandy M. Lucas

ABSTRACT. Client advocacy and social justice are topics of increasing importance in clinical practice. This study addresses the pragmatics of client advocacy in daily MFT (Marriage and Family Therapy) prac- tice using qualitative case analysis. Researchers used Kvale’s (1996) interview and analysis procedures to access detailed descriptions of the lived experience of advocacy from the client’s perspective. The client’s descriptions identify subtle aspects of advocacy that expand its current definition and challenge the suitability of certain clinical techniques, es- pecially with diverse clients. Implications for practice include (1) con- ceptualizing advocacy as an attitude; (2) providing flexibility in service delivery; (3) collaborating with social services as a clinical intervention; and (4) promoting self-advocacy. doi:10.1300/J085v18n01_04 [Article cop- ies available for a fee from The Haworth Document Delivery Service: 1-800- HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2007 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Advocacy, marriage and family therapy, case study, qualitative research

Diane R. Gehart is Associate Professor, California State University, Northridge, CA. Brandy M. Lucas is a doctoral student at Texas Tech University, Lubbock, TX. Address correspondence to: Diane R. Gehart, Department of Educational Psychol-

ogy and Counseling, California State University, 18111 Nordhoff, Northridge, CA 91330 (E-mail: dgehart@csun.edu).

Journal of Family Psychotherapy, Vol. 18(1) 2007 Available online at http://jfp.haworthpress.com

© 2007 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J085v18n01_04 39

Client advocacy and the related issue of social justice are issues of increasing importance in clinical practice. With few exceptions, mar- riage and family therapists have not been on the forefront of these movements (Laszloffy & Hardy, 2000; McGoldrick, 1998). Nonethe- less, marriage and family therapists have begun to meaningfully wrestle with questions related to social justice. Johnson (2001) challenges the idea that marriage and family therapy (MFT) as a profession can affect changes at the societal level because MFTs are not trained to intervene at broader systemic levels. If family therapists are not positioned to di- rectly intervene in matters of social injustice, then how is an individual clinician to respond when these issues are brought into the therapy room by clients experiencing injustice and challenges due to their ethnicity, race, gender, sexual orientation, social economic class, country of ori- gin, religion, language, or similar factors? Does an individual clinician have an ethical responsibility to address issues of subtle and gross social injustice in the lives of their clients? Is it possible to not address these issues? After all, is no response in effect a response? Assignment: Relationship Between Qualitative Analysis and EBP

We propose that the pragmatic answers to these questions are best conceptualized by clinicians not in terms of social justice but client advocacy. For those who work closely with marginalized populations, it is readily evident that family therapists can and do “heal the world in 50-min intervals” (Hardy, 2001, p. 22). Rather than ask can or should family therapists affect societal change, this article addresses practical ways in which a clinician can make a difference in everyday practice. This article provides a real-world glimpse of client advocacy by describ- ing the process in an MFT private practice setting based on case analysis.

CLIENT ADVOCACY IN CLINICAL PRACTICE

Client advocacy is most generally defined as helping clients to ad- dress institutional and social barriers that impede their ability to achieve goals or access needed services. Advocacy most often, but not always, involves addressing issues of social justice, and therefore the two tend to be discussed simultaneously. For the purposes of this article, client advocacy is referred to in the broadest terms, helping all clients address institutional and social barriers.

It must be conceded that as a discipline social work has long been at the forefront of issues related to client advocacy and social justice (Swenson, 1998). Social justice is easily recognizable as an organizing value within social work, and advocacy is addressed at both the micro

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and macro levels. However, Jordan (1987) argues that advocacy is “un- characteristic of everyday social work practice” (p. 135), particularly clinical social work. The apparent discrepancy may lie in the disci- pline’s emphasis on developing sensitivity and awareness of social jus- tice issues with fewer models for operationalizing these values in clinical practice. A similar pattern replicates in counseling and family therapy as well.

Professional counselors and counseling psychologists have begun pro- moting client advocacy as a core value within their professions (Ivey & Collins, 2003; Myers, Sweeney, & White, 2002). Similar to social workers, their emphasis has been to develop sensitivity to social justice issues: “Raising awareness about the needs of neglected populations and fighting for the civil rights of exploited people are profound human experiences that require counselors to be committed humanitarians” (Kiselica & Robinson, 2001, p. 391). This goal is codified in multicul- tural guidelines for the profession (Ivey & Collins, 2003). However, there is less agreement on how to operationalize these values. Some call for traditional political action at the broader social level (Kiselica & Robinson, 2001; Lee, 1998; Lee & Waltz, 1998; Toporek, 2000), while others call for more interdisciplinary collaboration (Bemak, 1998; Myers, Sweeney, & White, 2002). Both alternatives emphasize broad sys- tem-level interventions and do not address opportunities to intervene in clinical settings.

Similar to social workers and counselors, family therapists have fo- cused on increasing awareness of social justice issues with few models for operationalizing client advocacy. Grounding their work in social constructionist, critical, and feminist theories, McDowell and Shelton (2002) outline strategies for raising student awareness of social justice issues at various points in marriage and family therapy curricula. Simi- larly, Laszloffy and Hardy (2000) outline steps for addressing racism in family therapy, emphasizing the need to increase therapists’ racial sensitivities and abilities to actively respond to incidents of racism. Although they focus primarily on addressing forms of racism in the therapeutic relationship and dialogue, they specifically identify advo- cacy as a means to address racism when it is part of the presenting problem: “Therapists can serve as advocates on behalf of clients to address unjust situations, wherever these may occur (schools, the work- place, etc.)” (p. 42).

Aponte (1994) includes advocacy in his work with the poor. He warns that “in today’s politically correct atmosphere, many therapists and professional associations have determined that they should be the

Diane R. Gehart and Brandy M. Lucas 41

source of solutions for today’s social problems” (p. 11) and thereby impose their values on clients. Instead, he proposes that marginalized populations such as the poor are more in need of reconnecting with tra- ditional community resources and strengthening of spirit than they are of social services. In working with the poor, he identifies two ap- proaches to advocacy: direct and analogue interventions. In direct in- terventions, the therapist actively participates in conversations with outside systems related to the problem, such as schools, medical profes- sionals, and social services. Analogue approaches involve intervening on dysfunctional structural patterns at more accessible levels of the sys- tem and allowing the changes at one level to transfer to others. For ex- ample, by creating opportunities for a client to assertively interact with a therapist in session, the client can transfer this style of relating to other professionals.

Ecosystemic approaches have offered the most detailed models for advocacy in MFT. Imber-Black (1988) details an ecosystemic model, for working with families and larger systems, that provides a frame- work for client advocacy. Her model includes systemic assessment of broad system boundaries, triads, problem definitions, and binds and prescribes interventions using isomorphism and various forms of rit- uals. This ecosystemic model provides therapists with a model for ad- vocating in cases involving labeling, stigmatism, and secrets. More recent evolutions of ecosystemic theory incorporate postmodern con- cepts, such as a strength-based perspective and collaborative relation- ships with clients, to work with families and social service systems (Pulleyblank Coffey, 2004).

Postmodern therapists offer a unique approach to social justice and client advocacy. Narrative therapists have been active spokespersons regarding issues of social justice (Zimmerman & Dickerson, 1994), and the relational stance of narrative therapists often embodies a social justice ethic (Author, 2003). Narrative therapy provides a theoretical rationale and clinical approach for working with the effects of domi- nant social discourses, a concept frequently neglected in many thera- peutic models. Narrative therapists position themselves as advocates at the individual level by changing how a person relates to oppressive dominant discourses and increasing the person’s sense of community (Freedman & Combs, 1996). However, descriptions of narrative ther- apy generally focus on advocacy that occurs within session and with friendly “audiences” rather than engaging broader social service sys- tems (Freedman & Combs, 1996; White & Epston, 1990).

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Grounding their work in social constructionism, collaborative thera- pists have developed a postmodern approach to advocacy. Problems are conceptualized as emerging through dialogue, and therefore, the thera- peutic process requires that the therapist involve not only the client and family but involved professionals, extended family, and others in dia- logue about the problem (Anderson, 1997). Engaging multiple voices allows for clients, therapists, social workers, and other professionals to better understand each other. In this process, the client’s perspective is considered equally alongside professional views of the situation, a pro- cess that is referred to as acknowledging client expertise (Anderson & Goolishian, 1992). Additionally, collaborative therapists are “public” with their clients about the business of therapy including conversations with other professionals, social services, and legal institutions. By mak- ing these conversations public, therapists open many avenues for advo- cacy. For example, St. George and Wulff (1998) work collaboratively with clients in drafting letters to courts and other interested parties, in- creasing clients’ sense of autonomy, initiative, and responsibility.

FROM AWARENESS TO ACTION

Mental health practitioners have made strides in raising awareness of social injustice issues, and now the task is translating this increased awareness into action. The majority of advocacy approaches are based on existing theories, which are adapted and/or applied to advocacy work, such as the work of Imber-Black (1988) and Aponte (1994). This study represents an attempt to develop guidelines for advocacy based on one client’s lived experience of what advocacy is and how it was enacted over several years of treatment in private practice and social service set- tings. The purpose of this study is not to produce generalizable results but to systematically capture the richness and detail of one client’s lived experience in order to generate client-informed guidelines for advocacy practices. Such an approach is consistent with the ethic of advocacy, which demands that the client’s voice be included in this work.

QUALITATIVE CASE STUDY IN ADVOCACY

The following case study involves an in-depth interview with a client about her experiences of client advocacy. In an unusual departure from most research interviews, this interview was initiated by the client whose hopes were that therapists could learn from her experiences. One year

Diane R. Gehart and Brandy M. Lucas 43

after the termination of treatment, the client approached her former ther- apist (DG) and asked if there was some way to share her knowledge in a useful way with students in the therapist’s training courses. The client said she did not feel able to prepare a formal lecture and asked if the therapist could interview her. The client set the agenda for the interview, which was the advocacy agenda. Assignment: Relationship Between Qualitative Analysis and EBP

The client had been in therapy for six-and-a-half years; during the last four years of treatment, she was in individual therapy with a family thera- pist in private practice (DG). She was a 17-year-old Caucasian living in a homeless shelter with her mother at the start of treatment with this thera- pist. She had been in and out of a county mental health system and non- profit counseling since age 15 when a close relative was arrested for sexually abusing her. Over the course of therapy, she was admitted four times to a 24-hour crisis center for suicidal ideation and attempts; was in a county day-treatment program for two months; received case manage- ment from county mental health and Victims of Crime; was seen by a county psychiatrist; was briefly involved in two sexual abuse groups and day-treatment groups; and was in a welfare-to-work program.

The interview was conducted from a social constructionist perspective (Gergen, 1994) using Kvale’s (1996) qualitative interview and analysis techniques. Similar to Anderson’s (1997) conversational questions, the interview questions were designed to obtain rich descriptions from the client about her lived experience without structuring the interview from a preconceived perspective on advocacy or predefined professional con- structs. A social constructionist perspective recognizes that it is impossi- ble for a researcher to be completely bias-free; however, every attempt was made to set aside interviewer bias and ideas by taking a “not know- ing” position (Anderson, 1997). The interview was transcribed and the authors separately coded the interview using Kvale’s (1996) analysis pro- cedures; particular attention was given to “reading against” emerging cat- egories, and ensuring all dialogue was coded. The client reviewed the results to ensure that her words and intentions were accurately repre- sented; she made no corrections or additions to the results or manuscript.

RESULTS

Human Connection

The most frequently addressed theme in the interview was the pres- ence of a “human connection”; the import of this factor is illustrated in

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the relative volume of the interview dedicated to this concept compared with the other two sets of themes, which address activities related to ad- vocacy (see Figure 1). The client emphasized that she benefited from services when she felt like she mattered to the therapist at a human level. She said she felt that she was just a “paycheck” to many in the social ser- vice system and that she believed those others were “not in it to help other people.”

Failure of Connection

The client describes several failures to connect with social service workers and therapists. The behaviors that she described as severing connection are commonly taught and practiced within the field and are not examples of unethical or professional behavior. The client’s com- ments about the failure to connect addressed two areas: therapist/social service worker expecting certain behaviors and the more general issue of a rigid delivery system at a broader level. Assignment: Relationship Between Qualitative Analysis and EBP

Diane R. Gehart and Brandy M. Lucas 45

FIGURE 1. Summary of Themes

Therapist/Social Service Worker Expecting Certain Behaviors

One county mental health therapist “basically told me when I was ready to talk to let her know. And she turned around at her desk and started doing paperwork. . . . [that made me feel like] she wasn’t on my side.”

I didn’t know how to say, “Hey, look, you know, I’m falling apart.” And I didn’t know how to tell that to people.” [The suicide at- tempts were actions that communicated this need when she couldn’t say the words.]

Rigid Service Delivery

Mentally I felt like I was still you know, stuck back in childhood. But I wasn’t a child. And I needed to be able to do therapy my way, whatever worked for me. And I didn’t feel like I was getting that, you know. I felt like they [social services] wanted me to do it their way. Assignment: Relationship Between Qualitative Analysis and EBP

One of the therapists I was seeing over there [non-profit agency] told me that she only dealt with the sexual abuse. . . . And she told me that I needed a new therapist. “I can’t deal with all of this [her other life problems]. I’m not that type of therapist.”

When assigned to day treatment group, I said, “This is stupid. You know, if I want group therapy, I will go ask somebody for a smaller group or something.”

After trying to commit suicide, I was lying in a hospital, and I was scared to death thinking, “Oh, great, I finally found somebody I can trust, and now she’s not even going to be my therapist anymore.” [A fear based on prior experiences in the social service system where therapists were changed due to her needing a new level of care.]

Successful Connection

The client described successful connection when the therapist or social service worker not only saw her as a person but also was genuine in challenging her during the therapy process. The connection she described is not Pollyannaish but rather a balance of supportive and challenging

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behaviors. This balance led the client to conclude that she needed to be an advocate for her own progress in therapy.

Balance of Support and Challenge

Because I felt like if [the therapist] didn’t push me, it was never going to be talked about. And I was never going to heal from it. It was just going to destroy my life; destroy my family.

It was “just the way [the therapist] did therapy; that I had no choice but to talk about what happened. [She] had a way to make me talk about it and not make me feel like . . . it wasn’t my fault.”

Self-Advocacy

That’s when I realized that I needed to be the one to talk and not wait until the last five minutes of session before we started talking about something heavy.

And a lot of that came from [the therapist] telling me, you know, that that I could fix these things, you know. And that I didn’t al- ways need somebody to help me to fix all these problems.

Discussion

The client emphasized that the quality of the connection with a ser- vice provider was the most critical aspect to advocacy. When service providers had narrowly defined expectations and rigid treatment possi- bilities, advocacy was impossible. Many traditionally sanctioned be- haviors severed connection, such as waiting for the client to take initiative to speak, transferring clients due to therapist expertise, and therapist- directed treatment planning. On the other hand, successful connection did not always fit neatly within traditional therapeutic boundaries. For example, the client inquired about general details of the therapist’s life; would comment on changes in the therapist’s personal appearance (e.g., change from glasses to contacts); and would comment about events at the counseling setting. The relationship was down-to-earth and involved a collaborative two-way exchange (Anderson, 1997) than more tradi- tional approaches might advocate. Simply following standard practices did not assure that the therapist was doing what is necessary to success- ful connect with clients, and in fact common practice sometimes prohib- ited what needed to occur. Assignment: Relationship Between Qualitative Analysis and EBP

Diane R. Gehart and Brandy M. Lucas 47

Active Advocacy with Outside Agents/Agencies

The client reported many struggles accessing social services and a consistent sense of being misunderstood within the system. At the same time, the client felt helpless in terms of advocating for herself in a com- plex system of professionals given her emotional and social situations. The client reported that active intervention on the part of the therapist was necessary at certain points to help navigate the system.

Feeling Misunderstood by Social Services

They had a hard time seeing the depression. All they saw was the ornery, non-cooperative [side].

I still felt suicidal and they [the crisis center] sent me home.

In the day-treatment program, she was put in a group with “a lot of people that were in there with me were not people who had been sexually abused. . . . And once again I felt like I was out of place.”

Discussion

In large social service systems, diagnoses are often made based on a single diagnostic interview during which little emphasis is placed on build- ing the type of human connection described above. This approach often leads to misunderstanding clinical issues and underestimating strengths of diverse clients because of misinterpreted behaviors and words during the cross-cultural exchange. In this case, the client’s pervasive anger, par- ticularly with the social service system, led to a diagnosis of borderline personality disorder and subsequently the ineffective handling of more significant mental health issues. When the therapist was able to intervene by providing necessary diagnostic information (which included challeng- ing the Axis II diagnosis) and identifying appropriate treatment strategies for her more pressing mental health issues, the client was able to access needed services and her relationship with social service workers greatly improved. This type of advocacy requires marriage and family therapists to be well versed and confident in diagnostic assessment, a skill not tradi- tionally emphasized in the field.

Therapist Advocacy

At the time of my suicide attempt, “nobody asked me if I felt like I needed medication. It was never brought up by anybody.”

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Because I felt like if [the therapist] didn’t push meds, it was never going to be talked about. And I was never going to heal from it. And it was just going to destroy my life. Assignment: Relationship Between Qualitative Analysis and EBP

Discussion

At several points, the therapist intervened actively with social ser- vices on behalf of the client. In an unusual departure from common MFT practice, although a more common practice in social work, the therapist accompanied the client during an emergency hospitalization for active suicidal ideation in order to advocate for services the client had not been able to access in two prior visits to the same unit. This intervention enabled the client to safely continue in outpatient therapy, better advocate for herself on future occasions, and ended a series of emergency hospitalizations.

Client Agency Within Session

The client identified non-standard interventions as the most helpful in her treatment. Several interventions occurred outside of the therapy session, and many were spontaneous rather than planned.

Client-Generated Interventions

It was during that time when I would sit in the waiting room and wait for my mom that I started doing a lot of drawings . . . and sit in the waiting room and write poems. And, yeah. That was very therapeutic to me, actually. . . . It was very therapeutic to me being able to sit there and know everything would be okay [while writing].

And it was weird because I got the paper and I got the colored pen- cils and it was, like, you know, I went from there. And I didn’t even think about it. I just sat there and did it. It wasn’t something that I really thought about.

“Out-of-the-Box” Treatments

I couldn’t stand to sit and just talk inside of a little, teeny-tiny of- fice. Being outside, I felt like I was in control. . . . [and felt like I had] more confidentiality at the park than in the building basically.

Diane R. Gehart and Brandy M. Lucas 49

And actually I think one of the other things that helped a lot was when [she’d] bring her dog to therapy . . . I felt like I could talk more having the dog in there.

I never thought I’d get to the point where I get to be able to actually sit and talk to a bunch of other people about what happened. I mean, I always wanted to. . . . I always pictured myself talking to young girls, you know, who had been sexually abused.

Discussion

Client-generated and “out-of-the-box” treatments can be seen as an- other form of advocacy in the sense that the therapist is flexible and willing to do whatever is reasonably possible to meet the client where she is at. In a sense, the therapist advocates for the client in relation to the standardized treatment boxes and frameworks. The advocacy work of Aponte (1994) and Anderson (1997) incorporate such interventions.

IMPLICATIONS FOR PRACTICE

This client’s experience of advocacy outlines a complex and multi- level process that is perhaps best conceptualized as an attitude rather than a set of specific activities. Therapists need to reexamine the com- mon perception of client advocacy occurring primarily with external systems. From the client perspective, advocacy is enacted on many lev- els and is integrated throughout the therapeutic process, with the major- ity of advocacy occurring within the immediate therapeutic relationship rather than with external systems. Several guidelines can be derived from this case study for integrating an attitude of advocacy into daily MFT practice. Assignment: Relationship Between Qualitative Analysis and EBP

Advocacy as Attitude

Client advocacy is a mindset that is revealed in how the therapeutic relationship is formed, how interventions are conceptualized and deliv- ered, and how therapists work with clients and their social and service delivery systems. Within the MFT literature, social constructionist con- ceptualizations of the client-therapist relationship have made signifi- cant movements towards embodying an attitude of advocacy and have been incorporated into recent ecosystemic work (Pulleyblank Coffey, 2004). Anderson and Goolishian’s (1992) concept of the “client as

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expert” has been particularly influential. Clients are recognized for their expertise in terms of their life and what does and does not work for them; the therapist’s expertise is facilitating a process that helps clients resolve their problems utilizing client expertise and knowledge. Ac- knowledging client expertise involves a sincere, non-evaluative curios- ity in how clients construct and make sense of their world. Such an attitude reduces the possibility of the rigid service delivery and unrealis- tic expectations of clients, as was reported in this study. In terms of ad- vocacy, the important byproduct of viewing the client as expert is not the knowledge gleaned but that such a stance brings a more humane and down-to-earth quality to the therapeutic relationship. As was illus- trated in this study, following standards of practice and traditionally sanctioned therapist behaviors is not always consistent with an attitude of advocacy. If a therapist or the field as a whole wants to increase advo- cacy in clinical work, therapists must scrutinize their habits of relating to maximize opportunities for promoting client advocacy. Assignment: Relationship Between Qualitative Analysis and EBP

Advocacy Attitude versus Social Justice

There is an important distinction between an attitude guided by advo- cacy as described by this client and attitudes of social justice that some- times appears in the literature and professional dialogue (see Johnson, 2001). If social justice is interpreted as needing to change oppressive so- cial systems, the human element is often overshadowed in the immediate therapeutic situation by the agenda to address broad system changes. In- stead, when embodying an attitude of advocacy, the therapist becomes an agent for recognizing and bringing out a client’s dignity and humanity. When therapists advocate for clients in traditional ways (e.g., working with social services to find services) and less traditional ways (e.g., pro- moting self-advocacy and flexible service delivery), clients learn to advo- cate effectively and appropriately for themselves. In this way, both therapist and client interactions affect the broader system. This is perhaps a less direct means of addressing the social justice agenda, but it may be more useful and realistic for those who work in 50-minute intervals.

Flexibility in Service Delivery

This case study highlights the importance of flexible service delivery as a critical yet less visible element in client advocacy. In this case, ad- vocacy involved the therapist’s willingness to work with the client

Diane R. Gehart and Brandy M. Lucas 51

to identify interventions that were meaningful and useful to her, such as periodic sessions outdoors, creative use of waiting room time, appropri- ate group assignments, and opportunities to address community audi- ences. The therapist’s flexibility is an expression of a broader attitude of advocacy and requires that the therapist be creative in finding ways to tailor therapy to the client’s needs while remaining within legal and eth- ical guidelines. For example, if the client requests sessions outside as this client did, the therapist must discuss the risks to confidentiality. Such conversations are not only a legal mandate; they position the client to take a more proactive stance in the therapeutic process. Flexible mod- els to treatment delivery have demonstrated excellent potential and raise questions about the rigidity of many in- and out-patient treat- ment protocols, including the 50-minute session, professional bound- aries, and therapist role definition. For example, the highly flexible Open Dialogue approach to working psychosis developed by Jaakko Seikkula and his Finnish colleagues has resulted in reduced use of medi- cation, reduced relapse rates for psychotic patients, and increased em- ployment (Haarakangas, Seikkula, Alakare, & Aaltonen, 2004; Seikkula, 2002).

Collaborating with Social Services

Client advocacy is most commonly associated with collaborating with the client’s larger social service delivery system, such as physicians, so- cial workers, schoolteachers, and extended family. Although consid- ered standard practice, such collaboration cannot be assumed and is less frequent than would be ideal. Such contacts become a vehicle for advo- cacy when they are viewed as more than an “exchange of information” and are used as opportunities to intervene on each person’s construction of the problem and the relational patterns within the system. Imber- Black’s (1988) ecosystemic approach provides systemic family thera- pists with a detailed model for such work, and Anderson’s (1997) collaborative therapy provides postmodern therapists with a similar framework for using each conversation to promote change. Assignment: Relationship Between Qualitative Analysis and EBP

Competency in the Medical Model

Advocacy in this case required sufficient competency in the medical model, a model that is often at odds with the systemic and postmodern practices common in MFT. Communicating with social service agen- cies requires that therapists speak the institution’s language, which is

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typically the medical model. As in this case, successful advocacy re- quires the ability to make differential diagnoses and justify these diag- noses with other professionals in the system. In this situation, the client was not receiving proper treatment and was denied access to resources (i.e., medication) because of the way she was diagnosed: the focus was on Axis II rather than Axis I symptoms. In addition, crisis situations often require the therapist to help the client navigate systems steeped in the medical model. The therapist’s ability to explain these systems and their practices to clients enables clients to better access these resources and make sense of their experiences. Therefore, MFTs wanting to im- prove their advocacy skills need to become more comfortable with and competent in the medical model than is typical in the field. Assignment: Relationship Between Qualitative Analysis and EBP

Promoting Self-Advocacy

Ideally, client advocacy has the ultimate goal of teaching clients to advocate for themselves. Learning how to negotiate large bureaucra- cies, whether a public social system or managed health maintenance or- ganization, requires a proactive approach and effective communication. These skills transfer to more successful personal and work relation- ships, a perennial goal for MFTs. Family therapists have several models for promoting self-advocacy. Aponte (1994) describes how the thera- pist can work with clients to advocate for themselves in session and help them transfer this to other relationships. In a collaborative approach (Anderson, 1997), the therapist invites the client to join conversations with involved parties, giving clients an opportunity to experience the process of advocacy in vivo and learn from role modeling and engaging in the process with therapist support. Promoting self-advocacy should be the preferred modality and the primary goal of any advocacy work to ensure long-term benefits. Assignment: Relationship Between Qualitative Analysis and EBP

Training Implications

Increasingly social justice and advocacy are considered standard com- ponents in training. The current draft of Core Competencies developed by the American Association for Marriage and Family therapy includes ad- vocacy: “Advocate for clients in obtaining quality care, appropriate re- sources, and services in their community” (AAMFT, 2003, p. 5). This definition emphasizes one aspect of advocacy as it has been defined here: collaborating with social services. In addition, educators and super- visors should attend to the more subtle aspects such as attitude, treatment

Diane R. Gehart and Brandy M. Lucas 53

flexibility, and promoting self-advocacy. The current trend in mental health disciplines to emphasize awareness of social justice is an important first step in developing an attitude of advocacy (see McDowell & Shelton, 2002). Trainees must also be trained to transfer this awareness into clinical behaviors using models provided by systemic (Imber-Black, 1988) and/or collaborative models (Anderson, 1997).

CONCLUDING THOUGHTS

As family therapists become more engaged and skilled in working with diverse and multiproblem families, the need for client advocacy becomes clearer. Intervening at the individual or family level is not al- ways sufficient or the most efficient route to change. Therapists inter- ested in increasing their client advocacy skills will find systemic and postmodern foundations for such work. However, as the client in this case study indicates, client advocacy involves more than engaging in certain behaviors, such as making phone calls to social workers or writ- ing letters to the courts. Instead, advocacy is an attitude that permeates the client-therapist relationship and approach to treatment; it is a com- mitment that is made to consider the family and the broader system in which they and their problems are embedded and enacted. Such an atti- tude requires therapists to revise their identities and treatment foci to en- compass a broader terrain than a single family’s functioning by thinking and working at the broader community and social levels. In that way, therapists do “heal the world in 50-min intervals” (Hardy, 2001, p. 22). Assignment: Relationship Between Qualitative Analysis and EBP

REFERENCES

American Association for Marriage and Family Therapy. (2003). Core competencies draft. Alexandria, VA: Author.

Anderson, H. (1997). Conversations, language, and possibilities: A postmodern ap- proach to therapy. New York, NY: Basic.

Anderson, H. & Goolishian, H. (1992). The client is the expert: A not-knowing ap- proach to therapy. In S. McNamee & K. Gergen (Eds.), Social construction and the therapeutic process (pp. 25-39). Newbury Park, CA: Sage.

Aponte, H. (1994). Bread and spirit: Therapy with the new poor. New York, NY: Norton.

Bemak, F. (1998). Interdisciplinary collaboration for social change: Redefining the counseling profession. In C. C. Lee & G. R. Waltz (Eds.), Social action: A mandate for counselors (pp. 279-292). Alexandria, VA: American Counseling Association.

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Freedman, J. & Combs, G. (1996). Narrative therapy: The social construction of pre- ferred realities. New York, NY: Norton.

Gergen, K. J. (1994). Realities and relationships: Soundings in social constructionism. Cambridge, MA: Harvard.

Haarakangas, K., Seikkula, J., Alakare, B., & Aaltonen, J. (2004). Open dialogue: An approach to psychotherapeutic treatment of psychosis in Northern Finland. Manu- script submitted for publication.

Hardy, K. V. (2001). Healing the world in fifty-minute intervals: A response to “Fam- ily therapy saves the planet.” Journal of Marital and Family Therapy, 27, 19-22.

Imber-Black, E. (1988). Families and larger systems: A family therapist’s guide through the labyrinth. New York, NY: Guilford.

Ivey, A. E. & Collins, N. M. (2003). Social justice: A long term challenge for counsel- ing psychology. Counseling Psychologist, 31, 290-298.

Johnson, S. (2001). Family therapy saves the planet: Messianic tendencies in the fam- ily systems literature. Journal of Marital and Family Therapy, 27, 3-11.

Jordan, B. (1987). Counseling, advocacy, and negotiation. British Journal of Social Work, 17, 135-146.

Kiselica, M. S. & Robinson, M. (2001). Bringing advocacy counseling to life: The his- tory, issues, and human dramas of social justice work in counseling. Journal of Counseling & Development, 79, 387-397.

Kvale, S. (1996). Interviews. Thousand Oaks, CA: Sage. Laszloffy, T. A. & Hardy, K. V. (2000). Uncommon strategies for a common problem:

Addressing racism in family therapy. Family Process, 39, 35-50. Lee, C. C. (1998). Professional counseling in a global context: Collaboration for inter-

national social action. In C. C. Lee & G. R. Walz (Eds.), Social action: A mandate for counselors (pp. 293-304). Alexandria, VA: American Counseling Association.

McDowell, T. & Shelton, D. (2002). Valuing ideas of social justice in MFT curricula. Contemporary Family Therapy: An International Journal, 24, 313-331.

McGoldrick, M. (Ed.). (1998). Re-visioning family therapy: Race, culture, and gender in clinical practice. New York, NY: Guilford.

Myers, J. E., Sweeney, T. J., & White, V. E. (2002). Advocacy for counseling and counselors: A professional imperative. Journal of Counseling and Development, 80, 394-402.

Pulleyblank Coffey, E. (2004). The heart of the matter 2: Integration of ecosystemic family therapy practices with systems of care mental health services for children and families. Family Process, 43, 161-174.

Seikkula, J. (2002). Open dialogues with good and poor outcomes for psychotic crises: Examples from families with violence. Journal of Marital and Family Therapy, 28, 263-274.

St. George, S. & Wulff, D. (1998). Integrating the client’s voice within case reports. Journal of Systemic Therapies, 17, 3-13.

Swenson, C. R. (1998). Clinical social work’s contribution to a social justice perspec- tive. Social Work, 43, 527-537.

Toporek, R. L. (2000). Developing common language and framework for under- standing advocacy in counseling. In J. Lewis & L. J. Bradley (Eds.), Advocacy in

Diane R. Gehart and Brandy M. Lucas 55

counseling: Counselors, clients, and community (pp. 5-14). Greensboro, NC: Caps Publications.

White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York, NY: Norton.

Zimmerman, J. L. & Dickerson, V. C. (1994). Using a narrative metaphor: Implica- tions for theory and clinical practice. Family Process, 33, 233-245.

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