Reworked Therapy Case to Humanistic and Family Systems

The Humanistic Approach

Models in the family therapies focus on the client’s family for perceptions of new choices or changes. The present trend in family therapy is to integrate several approaches as no single technique is sufficient to treat all clients (Lebow, 1977 cited in Goldenberg and Goldenberg, 2008, p.410). Family therapy is a theory and treatment technique (Goldenberg and Goldenberg, 2008, p. 402). Efforts are taken to improve the functioning of persons within the family so that the context of family is widened by combining the individual, the family and the surrounding community (Robbins, Mayorga and Szapocznik, 2003 cited in Goldenberg and Goldenberg, 2008, p.402). Client- centered therapy on the other hand focuses on the client as an individual; a congruent therapist stimulates a psychotherapeutic personality change in an incongruent client if he understands the moves of the therapist (Raskin, Rogers and Witty, 2008, cited in Goldenberg and Goldenberg, 1965 p. 141).

Virginia Satir and Carl Whitaker who are experiential family therapists believe that “troubled families require a growth experience derived from an intimate interpersonal experience with an involved therapist” (Goldenberg and Goldenberg, 2008, p. 411). Experiential therapists indicate that by self-disclosing their thoughts or ideas, they may be able to encourage families to be more honest and expressive of their feelings. They would also utilize their potential maximally to attain personal and interpersonal growth. Satir’s therapeutic method was to build self-esteem and communicate adequately and easily (Goldenberg and Goldenberg, 2008, p. 411). Whitaker shared his impulses and fantasies and human feelings which he had overcome through depathologised experiences when he undertook to resolving issues in families: he calls it symbolic experiential family therapy. Experiential family therapy is now seen in emotion focused-couple therapy (Johnson, 2004cited in Goldenberg and Goldenberg, p. 411). It is an attachment-theory-grounded experiential approach. The couple’s negative interactions are changed so that the emotional connection between the two is elicited. The concepts used by experiential therapists are “experience, encounter, confrontation, intuition, process, growth, existence, spontaneity, action and the here-and-now moment”. The involvement of the experiential therapist is a catalyst to the growth of the family members (Goldenberg and Goldenberg, 2008).

The experiential therapists adjust their approach based on the type of problem the family has. Some variations are shown by the different therapists. Whitaker uses the psychodynamic orientation and does not impose any preconceived interpretations on the family (1976 cited in Goldenberg and Goldenberg, 1965, p. 147). Kempler used principles of Gestalt therapy (1981cited in Goldenberg and Goldenberg, 1965, p.147). Kaplan and Kaplan followed the method of systems theorists (1978 cited in Goldenberg and Goldenberg, 1965, p.147). Experiential therapists relate to the present rather than the past. The therapist does not offer interpretations. He allows the family members to come out with their own experiences and interpretations (Goldenberg and Goldenberg, 1965, p. 148). Whitaker was a person who took the view that the roles therapist and client can interchange in a therapeutic intervention very early. This was a concept not accepted by most therapists (Neill and Kniskern, 1982 cited in Goldenberg and Goldenberg, 1965, 148). Whitaker also began believing in the inclusion of family in therapy after treating a case of schizophrenia.

Satir’s humanistic approach or the human validation process was founded by her in 2000 (Goldenberg and Goldenberg, 2008, p. 222). This experiential model focuses on the efforts of the therapist and the members of the family in achieving family wellness. There is believed to be an inherent feature in all families to help or rise to an occasion of need. The family is a body of balanced and nurturing relationships enabled through clear and effective communications among the members (Goldenberg and Goldenberg, 2008, p. 223). This experiential model adds to it the personal touch of the caring therapist. Expressing her feelings and thoughts spontaneously, the therapist encourages the family members to use the same frankness. Direct expression of emotions can help change fixed rules which can assist the patient (Goldenberg and Goldenberg, 2008). Satir believed the family to be a balanced system. A symptom in a patient is believed to be a “blockage in growth”. She intended to find out the sacrifices or “price” that each member pays to keep the system balanced (Goldenberg and Goldenberg, 2008, p.223). A symptom was the starting point for Satir to unravel the mystery behind it. The reasons could be found in the distorted relationships or the ignored or denied or projected or unnourished or the untapped regions of a person (Goldenberg and Goldenberg, 2008, p.223).

Satir believed that the growth and development process influences one’s potential. Human development is affected by the unchangeable genetic factors, learning experiences and the mind-body reaction (Goldenberg and Goldenberg, 2008, p. 224). The learning experiences are the longitudinal influences occurring after birth. Self-identity is formed from the primary survival triad which is composed of the father, mother and child. The child’s self-esteem or self-worth is a result of the constructive and destructive experiences of the interaction within the triad. The child is influenced by the adult communication patterns (Goldenberg and Goldenberg, 2008, p. 224). The mind, body and feeling triad is another factor which decides the growth and formation of the personality. There would be likes and dislikes or negative and positive values in each. This combination, called the therapeutic parts party is used by the therapist to enquire of the client as to his responses or values. Teaching him to use the parts in “a harmonious and integrated manner” forms part of the therapy (Goldenberg and Goldenberg, 2008. p.224). Helping the clients build their self-esteem and self-worth, Satir expanded their awareness. Discrepancies in the family communications were indicated and corrected. Each member of the family was encouraged to change their practices, values and thoughts so that new ones could be integrated into their family life. If the families were resilient, they would increase the possibility of new solutions to problems (Goldenberg and Goldenberg, 2008, p. 224).

Daniel’s problem- Case History

Daniel is a 66 year old retiree in good physical and mental health till he approached for assessment (Fallon,p.41 ). His problems began 9 months after retirement. Weight loss, sleep problems with frequent awakenings, daytime fatigue, memory problems and tingling and numbness were his initial complaints. The primary care physician determined that there was no infection or anemia.Electrolyte abnormalities were not present (Fallon, p.41). Thyroid abnormalities were ruled out. The Lyme enzyme-linked immunosorbent assay was negative. The only abnormality in the investigation was a slight increase in the blood glucose level. There was a history of hypochondriasis 12 years before which was not responding to SSRI treatment for hypochondriasis; ECT did the trick. This is the only psychiatric episode (Fallon, p.41).

Initial treatment plan and course

Daniel had Fluvoxamine 50 mg per day and 50 mg. increased every week till 300 mg. The low dosage was started to prevent adverse reactions in this highly anxious patient (Fallon, p.43). Weekly sessions of psychotherapy were provided. His wife too was asked to attend as Daniel was too anxious to submit to therapy. His hypochondriasis was severe and he was so self-absorbed. As he was frequently consulting his wife for reassurance, she also came for the sessions. A mild diabetic condition was detected by his initial doctor. The wife was a very patient person. After 5 weeks, Daniel had not improve. It was time for a re-diagnosis and treatment (Fallon, p.43).

Re-evaluation of diagnosis and treatment

Daniel could be having Lyme disease. He was living in a Lyme endemic area.

However he did not remember having any typical erythema nigrans rash diagnostic of Lyme disease (Fallon, p.43 ). At the 6th week, he developed a rash on his chest: 5 inches in diameter, red with crisp margin with faint discoloration in the center and not itchy. It was a typical rash.

Tentative diagnosis

This was Lyme disease caused by a spirochaete, Borrelia burgdorferi, which can like the syphilis spirochaete travel to the brain and cause neuropsychiatric symptoms (Fallon, ). Daniel’s symptoms can now be accounted for. Mania, psychosis, depression, memory loss and severe anxiety could be answered by the Lyme diagnosis. The first Lyme test had been a false negative which caused the diagnosis to be missed then (Fallon, p.44).

Revised and final diagnosis

The first ELISA test was positive but the Western Blot was negative (Fallon, p.46). The second laboratory test showed a negative ELISA but a positive IgG Western Blot with the full criteria of the CDC satisfied. Daniel did not want the investigatory lumbar puncture which is not always diagnostic. He however underwent the brain SPECT scan. A pattern of blood flow seen typically in encephalitis or vasculitis as in Lyme disease was seen (Fallon, p.47). There was a moderately or severely decreased blood flow through the brain in a patchy pattern. Some areas had more flow. The condition is heterogenous hypoperfusion.

After so many months of being misdiagnosed and treated with antipsychiatric drugs and ECTs, it has been found now that everything was useless. He has been now diagnosed as having Lyme’s disease which accounted for the neuropyschiatric part of his symptoms like the memory loss, tingling and numbness and the sharp shooting pains. Life had been a problem for Daniel and his wife but now knowing about the misdiagnosis, they are both feeling more miserable about the past few months of suffering and anxiety they had undergone.

The goals of Daniel’s therapy

The therapy aims to work around the presenting problems of Daniel: weight loss, sleep problems with frequent awakenings, daytime fatigue, memory problems and tingling and numbness. His undue anxiety over his illness has to be reduced. His manner had conveyed the picture of severe obsessive-compulsive patients. His distress was extreme and he kept repeating his symptoms and questions. He simply could not be reassured as he had suffered for long. His wife quietly supported him but looked extremely tired. Daniel was fairly convinced that he had cancer which caused him to lose 25 lbs very fast, in the previous spring till he was diagnosed as having Lyme disease. He had throbbing pulsations in his body, tingling in the hands and feet and sharp stabbing pains on his right. His daytime fatigue, episodes of memory loss and concentration problems were symptoms which needed to be solved. The therapeutic medication of antibiotics should remove most of his symptoms and the psychotherapy should permit him to lead a normal life that was his before the illness began.

The approach selected

Deciding to use the humanistic approach of Satir, the close family members which included the children and the sister’s family and the wife of, course were gathered at two sessions. This helped put together the Family Life fact chronology (Goldenberg and Goldenberg, 2008, p. 228). Mr.Daniel’s grandparents were rich planters. They had a big orchard of fruit trees which provided a high income allowing them to live a comfortable life. The grand-parents were warm people and inculcated the best of principles in their children. Daniel’s father remained with them and continued living in the ancestral home even after he was married. Daniel was the younger brother of the two children. When he married, his sister and her family of husband and two children moved to the house in the fruit orchards. They tended to the orchards. Daniel worked in a brokerage firm while continuing to live in the ancestral home. His wife remained at home and looked after the family as the parents were old and needed attention. Their two children, Mary and Peter are 35 and 32 years old respectively. They have married and moved out to distant towns where they earn a living. Daniel’s parents are no more. There was no history of anyone having a psychiatric problem.

Family Assessment and intervention

On family reconstruction, Daniel was found to have had a wholesome life with parents, cousins, uncle, aunt and grandparents (Goldenberg and Goldenberg, 2008, p. 229). Relationships were well-developed and his attachment to the people at home cannot be denied. He has a blissful relationship with his wife who adores him and has no complaints. When he married, his sister’s family moved out but they keep visiting the family at home. His two children continued the attachments in an exemplary manner. Daniel is close to his children who have become professionals in their own right and are earning well. The family reconstruction uses techniques of “Gestalt therapy, guided fantasy, hypnosis, psychodrama, role playing and family sculpting” (Goldenberg and Goldenberg, 2008, p.229).

The family members were gathered together at two sessions and a review of relationships was carried out. The aim was to recognize dysfunctional patterns in the family (Goldenberg and Goldenberg, 2008, p. 229). There was no evidence of unclear or incomplete or distorted relationships. Daniel’s wife is a placater by Satir’s classification of styles of communication. She behaves as if weak and self effacing. Always agreeing with Daniel, she apologized when Daniel became agitated at times. Trying to please Daniel, she was especially attentive to him and was able to let him be undisturbed with her silence or coax him gently into less anxiety. The other family members also did not fit into the blamer or super-reasonable or irrelevant styles. Most of them were either placater or congruent communicator (Goldenberg and Goldenberg, 2008, p. 225). The congruent communicator expresses opinions genuinely and sends messages in the right context (Goldenberg and Goldenberg, 2008, p. 225). These styles, except of the congruent communicator, are stances that help people from exposing their true feelings because they lack the self-esteem to be themselves. Placaters are afraid of disapproval if they speak up independently. Maybe the wife assumed this role because she felt that Daniel needed someone who could understand him and perhaps justify his actions to soothen his ruffles. She knows her husband well and understands that he was very good to her when he was well till 9 months back.

The “threat and reward” model of Satir was a world view that could apply to both Daniel and his wife (Goldenberg and Goldenberg, 2008, p. 226). Their relationship and identity have been based on their role by hierarchy. Daniel was the leader and she followed. The wife may have changed recently after the husband became ill. In the seed model, changes occur based on nurturing. Satir believed that proper nurturing could influence children like seedlings (Goldenberg and Goldenberg, 2008, p. 226). Part of the personality of Daniel could be the result of nurturing as the seed model indicates.

Rather than going straight to the problem and thrashing it out formally, Satir believed in being optimistic and transferring her good feelings by allowing the client and family feel good about themselves (Goldenberg and Goldenberg, 2008, p. 227). The therapist needs to create relationships with each member of the family. The day-to-day functioning and emotional experiences are shared with the therapist. Teaching them the congruent ways of communication, building their self worth, the therapist can also initiate changes in relationships. Daniel’s wife can be helped in this manner. They can also be helped to nourish their potentials as Satir did (Goldenberg and Goldenberg, 2008, p.227). Compassion and a down-to-earth approach can elicit the maximum responses from the family. Helping the families to recognize the goals of therapy, the therapist must be able to let them know what each can do to reach the goals. The role of intimacy can be stressed upon (Goldenberg and Goldenberg, 2008, p.227). Daniel and his family were not short of this and so the therapist’s job becomes easier. The healthy family has members asking for what they need, it being a place where needs are met and the flourishing of individuality is allowed (Goldenberg and Goldenberg, 2008, p.227). Individuality is not allowed in dysfunctional families and the sense of self worth is not cultivated.

The Family Systems Therapy

The systems of the family concept have wrought changes in individual, group, couple psychotherapy. The interactions of family members are focused upon and not the individual. Multiple causes may be found from among the members for a particular psychological problem: this is called circular causality (Okun, 1990, p. 291). The individual’s symptoms are maintained and stabilized by the relationships among the family members and the relationship is stabilized and maintained by the individual’s behavior. Auerswald (1987 cited in Goldenberg and Goldenberg, 2008, p. 295) has defined four paradigms within the family systems therapy: family systems paradigm, general systems paradigm, cybernetic systems paradigm and ecological paradigm. The family systems paradigm identifies the “family as an independent system from where individual psychodynamics and symptoms arise” (Okun, 1990, p. 295). The general systems paradigm identifies family as an organizational system which arranges systems in a hierarchy. The cybernetics systems paradigm defined systems as areas of circular information flow and homeostatic regulatory mechanisms. These three systems constitute the family systems therapy. The ecological paradigm defined the family as an evolutionary system which is continuously changing and is not included in the family systems therapy (Okun, 1990, p. 295).

There is no theory of psychotherapy (Goldenberg and Goldenberg, 2008, p.417). However there are certain common ideas involved. People are bound by social connections and this necessitates the collaboration of family members in therapy. Symptoms appear in a person from a series of relationships and interventions are best when the faulty interactions are changed. In conjoint sessions, the family is the therapeutic unit and family interactions are the triggers for stimulating change. Assessment of family systems and relationships within and without provide the clues for reorganizing. Assessment of individual psychopathology will not reveal the disruptions within the family systems (Goldenberg and Goldenberg, 2008, p. 417). Maladaptive or dysfunctional family interactions are to be changed; these form the goals of therapy.

The relationship at fault could be a monadic one where only one person is at fault; dyadic where two people or a couple could be having a faulty relationship; triadic is when interactions between 3 or more people are involved (Goldenberg and Goldenberg, 2008, p.418). Family therapists actively participate with families in a therapeutic relationship. Members would be able to change many of the dysfunctions for lasting periods. First order and second order changes have been identified (Watzlawick, Weakland and Fisch, 1974 cited in Goldenberg and Goldenberg, 2008, p. 419). Changes in the system if not involving the organization level is the first order change. If the organization is involved, it is a second order change. First order changes may not always work as negative feedback is involved. The second order changes are based on positive feedback (Goldenberg and Goldenberg, 2008, p.419).

Daniel’s psychotherapy

The first contact- Daniel’s therapy is begun when he asks for help (Goldenberg and Goldenberg, 2008). He has a problem and seeks help. His family is unable to resolve it themselves. The therapist tries to gauge whether the family members would arrive for the initial session. The client would be trying to decide if he has approached the right person (Goldenberg and Goldenberg, 2008, p. 419). The first contact was by telephone in Daniel’s case. The therapist must give the impression that he makes the rules for the sessions.

The initial session- As many family members as possible may be asked to attend this session. Members are asked to occupy whichever position they feel comfortable in (Goldenberg and Goldenberg, 2008, p.419). The seating arrangement that is the outcome will give the therapist some idea about relationships. All members must be equally important and each should be asked on how they have tried to resolve the issue themselves. The therapist and family together investigate further on what to do. They also decide on who is to attend further sessions. If the family prefers another therapist, they should be guided to another one. If they would prefer to continue here, treatment goals are defined (Goldenberg and Goldenberg, 2008, p. 420)

Engaging the family- From the first session onwards, a working alliance is built between the therapist and the family (Goldenberg and Goldenberg, 2008, p.420). An atmosphere is built where each member feels important and supported. They should feel comfortable enough to bring out related issues. If the safety of the atmosphere impresses the members, they may speak about other family issues.

Assessing family functioning- Learning more about the family is essential for any family therapy (Goldenberg and Goldenberg, 2008, p.420). Daniel is the main person who needs treatment while his wife can change her meek behavior and become more authoritative with her husband who needs more help than her. She can also contribute to the change in her husband. The session also needs to take into account who and how many can contribute actively to the therapy (Goldenberg and Goldenberg, 2008, p. 420). If there are any triggers for the episodes, they must be identified and eliminated. The intervention that would help the family must be identified. Assessment turns out to be an informal gathering and exchanging of information. Some therapists believe that an informal assessment made over a long period produces more information to guide the therapy (Minuchin, 1974 cited in Goldenberg and Goldenberg, 2008, p.421). The therapist observes to see how the family carries out its tasks and functions, how it creates alliances, the flexibility of the family rules in differing situations and the permeability of the boundaries to the outside world. Refined appraisals are thereby possible (Goldenberg and Goldenberg, 2008, p. 421).

History taking- Object relations family therapists believe in taking the history of the family (Scharff and Scharff, 1997 cited in Goldenberg and Goldenberg, 2008, p. 421). Attachments are understood to be related to family functions. In marital discord, the reasons for the couple selecting each other are significant. Bowen wants to get plenty of information based on evaluation interviews (1978 cited in Goldenberg and Goldenberg, 2008, p. 421). He would look for dysfunction that resulted from an episode. Information that came from a few generations back also could be significant. Bowen designed a genogram for three generations. Relationships are better understood from this genogram. Some family therapists who use the structural and strategic methods prefer to take the current family organization. Social constructionists also want to know how the members view the world (Goldenberg and Goldenberg, 2008, p. 422).

The methods from which the suitable can be picked to treat Daniel:

• Reframing of a problem so that it is seen in better light is one method (Goldenberg and Goldenberg, 2008, p.422). In Daniel’s case the therapist may put the issue of misdiagnosis in a changed manner. Daniel may be explained to about the difficulties of making a diagnosis of Lyme disease. He may be convinced that the investigations had misled the first practitioner. That the false negative was a common incident must be impressed upon Daniel. The meaning attributed to the behavior is now in a new perspective which can erase doubts. Daniel would understand when he feels better with the antibiotic treatment and the psychotherapy (Goldenberg and Goldenberg, 2008, p. 422)

1. Therapeutic double blinds-The family is told to continue to manifest their symptoms (Goldenberg and Goldenberg, 2008, p.422). The members are told this to get them to understand their symptoms while enacting them voluntarily. If the client manages to enact the symptom, he must have been doing it the same way earlier (Goldenberg and Goldenberg, 2008, p. 422). If the client resists doing it, the symptom would disappear. This could be applied to Daniel as his illness has been diagnosed and he has been given the antibiotic treatment; Daniel would easily give up his remaining symptoms.
2. Enactment– Structural family therapists would use this technique of role-playing to bring forth the issue of conflict and the members are allowed to resolve it themselves (Goldenberg and Goldenberg, 2008, p.422). The demonstration would tell the therapist how best to guide the members depending on their enactment which is a picture of what happens at home. The therapist can suggest structural changes in the family and new behaviors would result. This technique is especially useful where the parents’ conflict is passed onto their child (Goldenberg and Goldenberg, 2008, p.423).
3. Family sculpting– Members can direct the others and their perceptions of their role will reflect in their sculpting procedure. Satir’s experiential approach could use this technique.
4. Circular questioning– Systemic family therapists focus attention on the relationships or connections (Goldenberg and Goldenberg, 2008). Based on the perceptions of the members, each participant will have questions framed accordingly. The therapist can detect how each patient responds. The family will be able to detect where the conflict arose and how to change the situation (Goldenberg and Goldenberg, 2008, p. 422).
5. Cognitive restructuring-This is done to bring about behavioral change. The concept is that problem behaviors arise from maladaptive thought processes (Goldenberg and Goldenberg, 2008,p.423). The therapist tries to modify the client’s perceptions of the conflict. Ellis points out that the interpretation is the cause of the problem and it is this that must be changed (2005 cited in Goldenberg and Goldenberg, 2008, p. 423). Couples are usually the clients who need cognitive restructuring. Their perceptions change with the therapy. They realize that situations and conflicts can occur in normal life. It is how they are interpreted that causes problems (Goldenberg and Goldenberg, 2008, p.423). It is this attitude that must change.
6. Miracle question– Members are asked to picture a situation where their conflict has disappeared. Each member may give their comments and thoughts. In this manner, goals are identified and executed (Goldenberg and Goldenberg, 2008, p. 423)
7. Externalization– The problem is externalized and the members are told to explain how it could restrain them (Goldenberg and Goldenberg, 2008, p. 423). Here a member is not found fault with; it is a problem that needs change. The members are better able to find a solution to their problem.

Mechanisms of therapy by family therapists

Active problem solving is the dictum of family system therapists (Goldenberg and Goldenberg, 2008, p. 424). Current issues are focused upon. The distant past appears to have little significance. The past gains some significance only if applicable to the present behaviors (Goldenberg and Goldenberg, 2008, p. 424).

Mechanisms of psychotherapy

Structure of an organization is assessed for effectiveness by therapists (Goldenberg and Goldenberg, 2008, p. 424). They challenge rigid patterns that prevent members from behaving optimally. Helping the families to modify the rigidity, new rules can be adopted. This restructuring helps a family to be on its right track again (Goldenberg and Goldenberg, 2008, p.424).

Behavioral change is brought about differently by strategic therapists and systemic therapists (Goldenberg and Goldenberg, 2008, p. 424). Strategic therapy is possible if the therapist can control the treatment and stop the family controlling or manipulating it. Systemic therapists direct each member to perform a task or function which goes against the rules set for the family. The member is led to perform it breaking the rule. This allows them to get the idea that rules can be bent when necessary (Goldenberg and Goldenberg, 2008, p. 424).

Experiential change occurs when the members are allowed to experience some thing that they have not done before. Through open communication and self disclosing, the therapists guide the members of the family to drop bad habits and gain good ones (Goldenberg and Goldenberg, 2008, p.424).

Cognitive change allows therapists to empower the clients with insight and understanding. Intergenerational issues are discussed and awareness increased. Old accounts when exposed are settled. Early object relations are to be settled (Goldenberg and Goldenberg, 2008, p. 425).

Conclusion

The family therapy systems are the more popular trend in present times. The incorporation of the family for the therapy of one or more members is a significant manner of therapy which has good outcomes. The humanistic experiential model of therapy and family systems therapy have their advantages. Therapists are now using the family therapy in techniques which focused on the individual, couple or group previously. Two approaches of family therapy for Daniel have been highlighted.

References

Goldenberg, H. and Goldenberg, I. (2008). Family Therapy: An overview. (7th Ed.) Pacific grove, C.A.: Thomson Brooks/Cole Publishers

Goldenberg, I. and Goldenberg, H. (1965) Family Therapy: An overview (2nd Ed.), Monterey, California: Brooks/Cole Publishers

Johnson, S.M. (2004). The practice of emotionally focused marital therapy: Creating connections (2nd Ed). New York: Brunner-Mazel

Kempler, W. (1981). Experiential psychotherapy with families. New York, Brunner-Mazel

Lebow, J. (1977). The integrative revolution in couple and family therapy, Family process, Vol.36, p. 1-17

Okun, B.F. (1990). Seeking connections in psychotherapy. San Francisco: Jossey-Bass Raskin, N.J., Rogers , C.R. and Witty, M.C.

Robbins, M.S., Mayorga, C.C. & Szapocznik, J. (2003). The ecosystemic “lens’ to enderstanding family functioning. In T.L. Sexton, G.R.Weeks & M.S. Robbins (Eds.). Handbook of family therapy: The science and practice of working with families and couples. New York: Brunner-Routledge

The following references are not found in the pages provided. Kindly add them From Goldenberg and Goldenberg, 1965:

1. Whitaker, 1976
2. Kaplan and Kaplan, 1978
3. Neill and Kirsken 1982

From Goldenberg and Goldenberg, 2008:

1. Watzlamet, Weakland & Fisch, 1974
2. Scharff and Scaharff, 1997
3. Bowen, 1978
4. Ellis, 2005
5. Minuchi, 1974

From Okun:

1. Auerswald, 1987 NB I have added one more reference, Fallon. I have not added even the year in the in-text citation. Please do it on pgs. 5 & 6 and add it to the page of references.