Author: Jennifer Benjamin
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Agreements for Treatment- Step 1
#image_title The Referral Behavior—Why Naming It Clearly Matters (and Why It’s Not the Problem)
Every course of treatment begins with a referral behavior. A youth is aggressive. A child is refusing school. A caregiver is overwhelmed. A system is worried about safety. These behaviors are the reason therapy begins—but in systemic family therapy, they are not the reason therapy works.
Referral behaviors function as signals, not diagnoses of the system. They tell us where distress is concentrated, not where responsibility lives. When therapists mistake the referral behavior for the problem itself, treatment becomes narrow, reactive, and often ineffective. The family may comply temporarily, but the underlying interactional pattern remains unchanged.
Best practice requires that the referral behavior be named clearly and collaboratively. Families deserve transparency about what brought them into care and how the therapist understands that concern. At the same time, systemic therapists must explicitly distinguish between the presenting behavior and the relational context that gives it meaning.
For example, a child’s aggression may appear to be the primary issue. But aggression rarely exists in isolation. It often emerges within systems struggling with inconsistent caregiver leadership, unresolved trauma, or chronic stressors embedded in the family’s social ecology. Without clarifying this distinction early, families may assume therapy is about “fixing the child,” reinforcing blame and undermining engagement.
Agreements for treatment begin here. Therapists must clearly state:
- What the referral behavior is
- Who noticed the behaviors
- How did we get here
This clarity creates safety. It helps caregivers feel less blamed and more capable. It invites collaboration rather than compliance. It also sets realistic expectations: therapy is not about eliminating a behavior in isolation but about restructuring the relationships that sustain it.
When referral behaviors are framed systemically, families can begin to see the problem as shared rather than owned by one individual. This reframing lays the groundwork for all future agreements about participation, dosage, and responsibility for change.
In short, you cannot form an ethical or effective agreement for treatment unless everyone understands what brought them together—and what that behavior truly represents.
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The Winner of the Wicked Competition
#image_title As part of our Wicked Competition, participants were invited to apply Ecosystemic Structural Family Therapy (ESFT) concepts to the world of Wicked—and one submission stood out for its clarity, creativity, and clinical precision.
The winning entry mapped the family system using both an ecomap and a Negative Interactional Pattern (NIP). Featured here is the NIP, which places Nessarose, Elphaba, the Bear Nanny, Mayor Thropp, and Mrs. Thropp as part of the triangle.
Rather than focusing on individual pathology, the NIP highlights how each person’s responses are relationally organized and mutually reinforcing. Within this triangle, well-intentioned caregiving, protection, and authority intersect in ways that unintentionally intensify disconnection, over-responsibility, and emotional isolation—particularly for Elphaba and Nessarose.
From an ESFT perspective, the NIP illustrates how:
- Caregiver fear and societal pressure shape parental leadership
- Protective behaviors escalate rather than soothe distress
- Children are pulled into roles that strain attachment and emotion regulation
- The broader ecology (including loss, stigma, and power) amplifies family stress
What made this submission especially strong was its ability to show how everyone is doing the best they can within a system that needs support—not blame. The NIP becomes a roadmap for intervention, pointing clinicians toward strengthening leadership, clarifying roles, and shifting interactional sequences rather than “fixing” a single character.
Congratulations to our Wicked Competition winner for reminding us that even in Oz, behavior makes sense in context—and systems, not individuals, are where change begins.
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The Trauma of Being Unprotected
When Safety and Relationship Collide
#image_title Dec 28, 2025
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Wicked Characters as Family Systems Metaphors
🌪️ A playful, clinically grounded way to think about family dynamics through the world of Oz
Elphaba — The “Identified Patient” Who Carries the System’s Anxiety
Elphaba represents the youth who is labeled as “the problem” simply because the system doesn’t understand or accommodate their uniqueness.
In ESFT terms, she is the symptom bearer—not because she’s broken, but because her family, community, and social ecology project their fears and failures onto her.
Her journey mirrors the work of helping a child reclaim identity, voice, and relational belonging.
Glinda — The Caregiver Who Uses Performance to Maintain Harmony
Glinda embodies the caregiver (or sibling) who copes through positive affect, charm, and high sociability.
Her role keeps peace but often hides insecurity.
In systemic therapy, she symbolizes the family member whose over-functioning or “performer” role helps stabilize the system—but prevents vulnerability.
Her friendship with Elphaba demonstrates the healing power of authentic connection.
Fiyero — The Avoidant Attachment Partner Afraid to Choose
Fiyero mirrors the person in the system who avoids emotional engagement—“fun,” charming, but disconnected.
He represents a protective adaptation, not a flaw.
Through relationship with both Glinda and Elphaba, he learns the core principles of systemic change:- Responsibility
- Presence
- Emotional risk-taking
The Wizard — The Larger System That Creates the Problem It Claims to Solve
The Wizard symbolizes structural forces—policies, institutions, and leaders—that blame individuals while perpetuating dysfunction.
He is the metaphor for:- Oppressive systems
- Pathologizing narratives
- Blame-shifting structures
In family therapy terms, he is the “macro-system stressor” shaping how families respond to crisis.
Madame Morrible — The Rigid Hierarchy That Reinforces Dysfunction
Morrible represents the family system’s coercive hierarchy—a figure who uses fear, control, and manipulation to maintain order.
Her “weather patterns” metaphorically mirror how emotional climates in families are often shaped by the most powerful or reactive members.
Nessarose — The Child Caught in the Bind of Overprotection
Nessarose is the sibling who receives intense focus—overprotection disguised as care.
Her storyline reflects how enmeshment and over-dependence can limit growth and create resentment, despite good intentions.
Her dynamic with Elphaba shows what happens when families assign fixed roles (“the responsible one,” “the helpless one”).
Boq — The Marginalized Member Who Adapts Until He Breaks
Boq embodies the overlooked, underheard member of the system who tries to earn belonging through compliance.
His unmet needs eventually transform him—literally—revealing how suppressed emotions can reshape functioning.
He is the metaphor for accommodation patterns and role strain.
Dr. Dillamond — The Silenced Voice of Wisdom
Dillamond represents the voice in the system that sees the truth but is ignored or suppressed.
He symbolizes the disenfranchised perspective—the teacher, elder, or natural support whose insight is essential to systemic change, but often marginalized.
Dorothy (Part 2) — The Newcomer Who Exposes Existing Fault Lines
Dorothy is the outsider whose arrival destabilizes a fragile system.
Her presence reveals:- unresolved grief
- fractured alliances
- long-standing injustices
She is the catalyst that forces the system to confront its hidden patterns.
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Yale LGBTQ Mental Health Initiative
Yale offers LGBTQ-affirmative CBT training. Great opportunity for psychotherapy integration with ESFT.
https://medicine.yale.edu/lgbtqmentalhealth/centerlink-training-program
About
Since 2019, CenterLink (the Community of LGBT Centers) and the Yale LGBTQ Mental Health Initiative have been offering comprehensive trainings in LGBTQ-affirmative cognitive-behavioral therapy (CBT) for mental health providers serving LGBTQ clients.
Developed, tested, and refined over more than a decade by Yale researchers, LGBTQ-affirmative CBT is the first treatment shown across large-scale clinical trials to reduce depression, anxiety, substance use, and sexual risk among diverse LGBTQ community members. The treatment improves mental health and builds resilience by targeting the specific internal and psychosocial vulnerabilities that research shows are elevated among LGBTQ people due to early and ongoing exposure to LGBTQ-related stress.
Those who participate in one or more offerings of the Yale-Centerlink Training Program will gain the knowledge, hands-on skills, and confidence to implement LGBTQ-affirmative CBT. Most training offerings are open to professionals and trainees, including individuals for whom CBT is not their primary therapeutic modality.
Learn more about our upcoming training programs here.
Our Mission
The Yale LGBTQ Mental Health Initiative provides a home for scholars and scholarship devoted to understanding and improving the mental health of LGBTQ populations in the US and around the world.
LGBTQ individuals experience substantial disparities in mental health problems, from suicide to substance use. The Initiative applies Yale’s strengths in mental health, LGBTQ studies, and global health to solving this pressing public health challenge.
We achieve this mission through fostering highly collaborative research across schools and departments; sponsoring academic events meant to spark innovation in this field; and training and educating diverse future leaders in LGBTQ mental health research.
Our Initiative
The Initiative is housed within the Yale School of Public Health and Yale School of Medicine, Department of Psychiatry, and draws upon Yale’s interdisciplinary expertise to advance its mission.
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The Department of Education (ED) is moving forward with draft rules that will fundamentally change how graduate students finance their education
Andrew Benesh, PhD, LMFT-Behavioral Health Education and Community Development Professional comments on drafted rule changes.
I know there’s a lot of anxiety floating around regarding upcoming changes to student loan rules, and their anticipated effects on students.
The Department of Education (ED) is moving forward with draft rules that will fundamentally change how graduate students finance their education. Under the rule ED will propose, many healthcare professions are not classified as professional programs, but instead as graduate programs. “Graduate programs” will have a $20,500 annual limit, with a $100,000 total cap, while programs defined as “professional programs” will have a $50,000 annual limit, and $200,000 total cap. This means that many students, including MFT students, would be subject to significantly lower loan limits. This change will take effect on July 1, 2026, and will apply to new borrowers. The ED is expected to open this proposed rule up for public comment early next year, most likely in January.
AAMFT has been actively advocating for the inclusion of MFTs in the professional degree definition throughout the rulemaking process, including joining coalitions of health professionals advocating for a more expansive definition of professional degree. AAMFT and many other healthcare associations will be submitting public comments to ED on this proposed rule. AAMFT will alert members once the public comment period begins.
What can be done before the public comment period begins?
It is important for Members of Congress to hear from their constituents on this important issue, and to ask Members of Congress to make sure that ED includes MFTs and other healthcare professions under the professional degree definition in the final rule. Use this link to contact your Member:
https://lnkd.in/eZ6qQmaj
In addition, AAMFT wants to hear how federal graduate student loan program has supported your path to licensure and how these proposed limits would impact future students. Your stories will help show Congress the real-world impacts of these changes on current and future MFT students, as well as how these changes will exacerbate the shortage of behavioral health providers. Share your story here: https://lnkd.in/eBFKMdZh
hashtag#mentalhealth hashtag#MFT hashtag#GAMFT hashtag#Loans hashtag#familytherapy hashtag#behavioralehealth hashtag#advocacy hashtag#studenttherapistThe above is based Original Message:
Sent: 11-24-2025 04:04 PM
From: Neal SombkeHello Family TEAM members,
Thank you for your comments on this important issue. AAMFT has been actively advocating for the inclusion of MFTs in the professional degree definition throughout the rulemaking process, including joining coalitions of health professionals advocating for a more expansive definition of professional degree.
We have linked here two coalition statements AAMFT has signed on to within the last month that urge the Department of Education to classify MFT degrees and other healthcare degrees under a more inclusive professional degree definition.
Coalition of Providers and Programs
PARCA LetterThe Department of Education (ED) is moving forward with draft rules that will fundamentally change how graduate students finance their education. Under the rule ED will propose, many healthcare professions are not classified as professional programs, but instead as graduate programs. “Graduate programs” will have a $20,500 annual limit, with a $100,000 total cap, while programs defined as “professional programs” will have a $50,000 annual limit, and $200,000 total cap. This means that many students, including MFT students, would be subject to significantly lower loan limits. This change will take effect on July 1, 2026, and will apply to new borrowers.
The ED is expected to open this proposed rule up for public comment early next year, most likely in January. AAMFT and many other healthcare associations will be submitting public comments to ED on this proposed rule. AAMFT will alert members once the public comment period begins.
What can be done before the public comment period begins? The federal bureaucracy does listen to Congress. Therefore, it is important for Members of Congress to hear from their constituents on this important issue, and to ask Members of Congress to make sure that ED includes MFTs and other healthcare professions under the professional degree definition in the final rule. AAMFT has developed a grassroots message that you can send to your Members of Congress.
In addition, AAMFT wants to hear how federal graduate student loan program has supported your path to licensure and how these proposed limits would impact future students. Your stories will help us show Congress the real-world impacts of these changes on current and future MFT students, as well as how these changes will exacerbate the shortage of behavioral health providers. Please click here to share your story.
AAMFT continues to monitor the situation and how these changes will affect MFTs. If you would like to read about how these changes will affect MFTs, you can click this article. Please contact AAMFT at FamilyTEAM@aamft.org if you have any questions.
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Recording therapy sessions is a powerful tool for promoting professional growth and improving therapeutic outcomes.
Recording therapy sessions is a powerful tool for promoting professional growth and improving therapeutic outcomes. Without this practice, therapists miss out on valuable opportunities for feedback, self-reflection, and skill enhancement, which are essential for ongoing development.
The Importance of Feedback in Therapy
Feedback is a cornerstone of professional growth in any field, and therapy is no exception. For therapists, receiving feedback on their work is crucial to understanding how their interventions are perceived, identifying areas for improvement, and refining their techniques. Without recording sessions, it becomes challenging to obtain accurate and detailed feedback. Relying solely on memory or subjective impressions can lead to a skewed understanding of the session, missing out on subtle but important nuances in the therapeutic process.
Enhancing Self-Reflection
Recording sessions allows therapists to revisit their work with a critical eye, enabling them to analyze their interventions, communication style, and the overall flow of the session. This practice fosters self-reflection, helping therapists recognize patterns in their behavior that may be hindering or facilitating the therapeutic process. For example, a therapist might notice that they frequently interrupt clients or that they struggle to maintain a non-judgmental stance in certain situations. Identifying these patterns is the first step toward making intentional changes that can enhance the effectiveness of therapy.
Facilitating Supervision and Peer Review
Recorded sessions are invaluable in supervision and peer review processes. Supervisors and colleagues can provide more precise and constructive feedback when they can observe the session directly rather than relying on second-hand accounts. This external feedback is critical for identifying blind spots, challenging assumptions, and exploring alternative approaches. Without recorded sessions, therapists may miss out on these rich learning opportunities, limiting their professional growth.
Improving Client Outcomes
Ultimately, recording sessions and using the feedback to improve therapeutic skills leads to better outcomes for clients. When therapists are more aware of their strengths and weaknesses, they can tailor their approach to meet clients’ needs more effectively. This continuous process of learning and improvement ensures that therapists are providing the highest quality care possible.
Conclusion
If you aren’t recording your therapy sessions, you are likely missing out on key opportunities for growth. By incorporating session recordings into your practice, you can enhance self-reflection, receive valuable feedback from supervisors and peers, and ultimately improve your therapeutic effectiveness.