226

Marital and Family Therapies

BIBLIOGRAPHY

1. Alexander F, French T Psychoanalytic Psychotherapy. New York, The Ronald Press, 1946. la. Beck AT: Cognitive therapy for depression and panic disorder. Western J Med 151:9-89, 1989. 2. Beck S, Greenberg R: Brief cognitive therapies. Psychiatr Clin North Am 2: 1 1-22, 1979. 2a. Book H E How to Practice Brief Psychodynamic Psychotherapy: The Core Conflictual Relationship Theme Method. Washington, DC, American Ps~chologic~l Association Press, 1998. 3. Budman S, Gurman A: Theory and Practice of Brief Therapy. New York, The Guilford Press, 1988. 4. Burk J, White H, Havens L: Which short-term therapy? Arch Gen Psychiatry 36: 177-1 86, 1989. 5. Davanloo H: Short-Term Dynamic Psychotherapy. New York, Jason Aronson, 1980. 6. Ferenczi S, Rank 0: The Development of Psychoanalysis. New York, Nervous and Mental Disease Publishing Company, 1925. 7. Flegenheimer W: History of brief psychotherapy. In Horner A (ed): Treating the Neurotic Patient in Brief Psychotherapy. New Jersey, Jason Aronson, 1985, pp 7-24. 8. Goldin V Problems of technique: In Horner A (ed): Treating the Neurotic Patient in Brief Psychotherapy. New Jersey, Jason Aronson, 1985, pp 56-74. 9. Groves J: Essential Papers on Short-Term Dynamic Therapy. New York, New York University Press, 1996. 10. Groves J: The short-term dynamic psychotherapies: An overview. In Rutan S (ed): Psychotherapy for the 90s. New York, Guilford Press, 1992. 1 I . Hall M, Arnold W, Crosby R: Back to basics: The importance of focus selection. Psychotherapy 4578-584, 1990. 12. Horner A : Principles for the therapist. In Horner A (ed): Treating the Neurotic Patient in Brief Psychotherapy. New Jersey, Jason Aronson, 1985, pp 76-85. 13. Horath A, Luborsky L: The role of the therapeutic alliance in psychotherapy. J Consult Clin Psycho1 61:561-573, 1993. 14. Klerman G, Weissman M, Rounsaville B, Chevron E: Interpersonal Psychotherapy of Depression. New York, Basic Books, 1984. 15. Leibovich M: Short-term psychotherapy for the borderline personality disorder. Psychother Psychosom 35:257-264, 1981. 16. Malan D: The Frontier of Brief Psychotherapy. New York, Plenum Medical Book Company, 1976. 17. Mann J: Time-Limited Psychotherapy. Cambridge, Harvard University Press, 1973. 18. Olfson M, Pincus HA: Outpatient psychotherapy in the United States. 11: Patterns of utilization. Am J Psychiatry 151:1289-1294, 1994. 19. Sifneos P: Short-Term Anxiety Provoking Psychotherapy: A Treatment Manual. New York, Basic Books, 1992.

44. MARITAL AND FAMILY THERAPIES

Margaret Roath, M.S.W., LCSW

1. What a r e marital and family therapies? Marital and family therapies are therapeutic modalities whose focus of assessment and treatment is on the relationship, not on the individual. Assessment includes gathering data related to the following areas: History of the relationship Communication patterns, both Goals of the individuals in the relationship constructive and destructive Coping mechanisms which have been Description of the strengths of unsuccessful the relationship Precipitant for seeking therapy--why now? Unmet needs of the individuals or what changed? in the relationship Assessment of the precipitant for seeking marital or family therapy is especially important in determining the relationship equilibrium-which may have worked previously for all members of the relationship, but is now out of balance. The precipitant might be a change in external circumstances or a change within an individual that is affecting the relationship.
9

Marital and Family Therapies

227

Marital and family therapies identify these changes and then examine patterns of communication, behavior, and coping mechanisms which may have been destructive, not constructive, in responding to the identified changes. The goal of therapy is to provide the marriage and the family with new ways of responding that are helpful and constructive to the relationships. Sometimes, there is no acute precipitant to the request for marital or family therapy, but instead there are long-standing destructive patterns of communication that have been identified, and the married couple or the family are interested in changing those patterns.

2. What are the indicators for marital and family therapies?

Statements or complaints expressed by individuals that reflect concerns about the relationship and also show the inability to resolve those concerns. Indications might include internal and external changes within individuals in the relationship or changes within the relationship itself.

Internal and External Indicators for Marital and Family Therapy

INTERNAL CHANGES EXTERNAL CHANGES

A person, through individual therapy or through

life experience, is making a decision about whether to remain in the relationship

A person, through experience or therapy, realizes

Recently diagnosed illness of one of the marital or family members-the illness may mean death or adjustment to changing abilities Change in financial status through loss of a job or a decrease in pay Addition of members to the mamage or family: the birth of a child, an in-law or children of a previous marriage joining the family Children leaving home, which may exacerbate unresolved relationship issues for the mamage A decision to divorce which causes all relationships to be renegotiated

that he or she is of a different sexual orientation than originally believed

A person may be experiencing an internal crisis, such as a mid-life crisis, and desires to change or maybe end the relationship

Normal developmental changes of children, such as adolescence Developmental changes of adults, such as the wife desiring to return to a career after being a homemaker

3. What treatment models are used for marital and family therapies?
In the most common model for marital therapy, both partners of the marriage are seen together by one therapist. Sometimes one or both partners will also be in individual therapy. In preparation for the marital sessions, the individuals may be working on issues pertinent only to themselves or developing a better understanding of their needs as partners in a marriage. It is usually optimal for the individuals therapist not to be the couples therapist because the therapist may learn secrets which would compromise the marital therapy. However, when it is not possible or deemed optimal for separate therapists for each treatment modality (e.g., in rural areas), the therapist and the patients must establish clear boundaries regarding the content discussed in each treatment modality. When several therapists are involved, communication among them can be helpful to clarify that they are working together and not at cross-purposes. Confidentiality needs to be addressed by each therapist with their respective patient or patients. In the most common modelfor family rkerupy, all members of the immediate family are seen together. Concurrent individual therapy should be handled as noted above for marital therapy. Group therapy is another possible modality for both marital and family therapy. It affords the possibility of learning from others in similar situations and also the benefit of feeling less alone with the issues being addressed. Couples and families often can listen and integrate advice from others in similar situations better than they can integrate advice from therapists. A disadvantage is that each couples or familys specific issues may take longer to address because time is spent on developing relationships among couples or families. The therapists role is to facilitate interaction among participants.

228

Marital a n d Family Therapies

4. What is the role of the therapist in marital and family therapies? Typically quite active. The therapist assists marriage and family members in defining the problem and determining goals to address it. The therapist may need to stop certain behaviors and encourage others within therapy-for example, stopping one person from doing all of the talking and encouraging another to talk more. He or she also may have to direct marriage and family members to stop certain behaviors outside of the treatment session, such as marathon discussions which might escalate into arguments or physical actions. The therapist might suggest a time limit for all discussions which have not resolved an issue, and also set very specific rules prohibiting physical violence, both in and out of therapy. When individuals in a marriage or family cannot stop physical violence, a separation with strict guidelines for being together may be suggested. The therapist also reframes problems or feelings among marriage and family members by removing labels of good and bad and making statements about differences among the members. He or she may suggest problem-solving with the directive that if the solution is not effective, it only means that the participants, including the therapist, did not have all of the information necessary to develop a better solution. The therapist may give homework to the marriage and family members so that the therapy does not just take place in the office, but also becomes a part of daily home life. The therapist may serve as coach, educator, or mentor to the mamage and the family when destructive communication is observed, by giving specific examples of what to say or by participating in role-playing. The therapist joins with the marriage partners and the family to develop new coping mechanisms, communication skills, and negotiation skills to address the identified problems. 5. What assessment and treatment techniques are used by the therapist? The techniques of marital and family therapy focus on the relationships and relationship issues. Assessment Techniques Ask each individual to describe their sense of the problem and its history Ask each individual the same question that has been asked of another Identify nonverbal communication Ask each individuals reaction to what another has said Identify themes common to the relationship and individuals within that relationship Treatment Techniques Ask individuals to speak with I phrases, not you phrases, which sound accusatory Ask that each expressed need be accompanied by a proposed solution Assign homework or tasks that respond to the assessed problem Clarify-repeat what the other said and ask if the repeated statement was heard as intended
Many other techniques exist. Their common goal is strengthening the marriage or the familys bond even when the individuals feel polarized, disappointed, and angered at the time of therapy.

6. How long does marital or family therapy take? It is not possible to say specifically. However, it is possible to establish specific goals and assess at the end of each session or after an agreed-upon number of sessions whether the goals have been met and what will need to happen for any remaining goals to be met. The length of time needed depends on how much blame is present, how much desire or ability there is for the participants to move from blame to identification and problem solving, and how much empathy all members have for other marriage and family members. The more blaming, the less problem-solving behavior, and the less empathy, the longer the therapy will take. The more willing each individual is to examine his or her behavior and develop solutions for changing it, the less time therapy is likely to take.

7. Are there any patients with specific psychiatric diagnoses who should not be referred to marital or family therapy? Yes. If one member of a marriage or family is psychotic or so severely depressed that he or she is unable to focus cognitively on marriage and family issues, then such therapy is not recommended.

Marital and Family Therapies

229

Once treatment for psychosis or depression has occurred, however, there can be a referral for marriage or family therapy if the issues identified indicate the need for it. Otherwise, because marriage and family therapies focus on changes in behavior, coping mechanisms, and problem-solving, they have the potential to be successful if the members are motivated to pursue those changes, irrespective of the members DSM-IV diagnoses. Some research shows that marital and family problems may increase vulnerability to mood disorders, and those same problems may slow recovery or cause exacerbations of additional episodes of severe illness. Treatment to promote marital and family harmony may prevent recurrences of the illness. Family therapy may be very helpful in reducing severity or relapses for persons with schizophrenia. Family members often respond positively to information about mental illness and coping strategies and feel less alone when professionals are interested in working with them in management and caretaking. Partners and families of schizophrenics usually identify relapses earlier than the patient does; if they are working collaboratively with professionals, they can provide data that increase services being provided. Also, partners and families who have a positive relationship with professionals and are able to express their feelings and worries in marital and family therapy sessions are less likely to be intrusive or hovering, possibly causing the patient to express hostility and anger, which could precipitate a relapse. The intrusive or hovering behavior is referred to as expressedemotion behavior. The greater the level of this behavior, the more likely a relapse by the patient; the lower the level, the less likely.

8. Can marital and family therapies be effective if one of the members is resistant?
If one of the members displays resistance by not attending meetings, the issues in the marriage and the family may still be addressable, but with the understanding that the only ones who can change behavior are those willing to attend meetings. Thefocus cannot be on the person not present. If the resistant person attends the meetings, it may be possible to lessen the resistance by having everyone listen to and understand the reasons for the resistance. If an individual maintains resistance, a decision can be made for that person not to attend, and therapy can proceed for those members who are motivated.

9. Are marital and family therapies different for different cultures, races, ages, and sexual orientations? No. The assessment process remains the same, as does the treatment process. In other words, assessment and treatment always focuses on needs, expectations, complementarity of roles, communication, and behavior patterns. However, cultural differences between individuals in a marriage or a family may lead to different goals or expectations, and those differences need to be elucidated and clarified by the therapist.
10. Does there have to be a match with the therapist in the areas of culture, race, age, and sexual orientation? No, although couples and families do request it. Accommodating that request may facilitate the beginning process of therapy. However, it is not necessary because a competent therapist addresses the lack of complementarity in the beginning, which creates alliance-building.The alliance encourages the members of a marriage or family to express feelings, either negative or positive, about the lack of complementarity and allows the therapist to empathize with those feelings. The therapist also may encourage the couple or family to share information about culture, history, traditions, or lifestyle as a way to bridge the gap between those differences.
11. Are marriage and family therapies always successful in keeping marriage and family together and improving the relationships? No. Approximately 50% of the marriages that enter marital therapy end in separation or divorce. Some couples come to marital therapy when anger has created too great a distance and one, if not both, partners have already decided on separation or divorce. The therapy can be a forum through which to accomplish this goal. Sometimes one partner is hoping the other will connect

230

Marital and Family Therapies

with the therapist as a source of support in order to feel less guilty or fearful about abandoning the partner. Marital and family therapies are sometimes unable to promote change because the desire to change and enter into the unknown is weaker than the comfort of the known. The therapist shares that observation with a marriage and family in a nonjudgmental way, encouraging them to return should the situation change. Some marriages and families experience several attempts at therapy before they decide to make changes and risk the unknown. Part of the process in marital and family therapy is learning whether the members of a marriage or family can meet the needs expressed. If, through therapy, it is learned that needs cannot be met, decisions may be required to meet those needs other than through the marriage or family.

12. What are some of the controversial issues? The biggest issue today is Who are the family members? when the therapist is making decisions such as who to invite to family therapy sessions. The divorce rate has altered the composition of family systems and relationships. There may be parents, step-parents, children, step-children, half-siblings, grandparents, and step-grandparents. There also are gay and lesbian couples who may have ex-spouses by previous marriages. Children of those marriages will most likely be sharing time with both their homosexual and heterosexual parents. Another recent social phenomenon is the choice being made by both men and women to have children outside of marriage. Children of such relationships may be living with both biologic parents, a single parent, or one biologic parent and a significant other of that biologic parent. Another controversial issue is whether couples and families dealing with domestic violence should be treated with marital or family therapy. Some professionals say Never, because they believe that marital and family therapies support blaming the victim. Those professionals say that only the perpetrator needs to be in therapy; however, the basic tenet of couples therapy is that both people contribute to destructive behavior. Other professionals argue that the domestic violence occurred in the context of a relationship and that the most helpful treatment program is individual help for the perpetrator in addition to therapy that addresses marital or family relationships. It may be that the decision should not be viewed as either-or, but rather as a clinical decision that depends on whether or not the goal is to reunite the couple or family. BIBLIOGRAPHY
I . Balcom D, Lee R, Tager J: The systemic treatment of shame in couples. J Marital Family Ther 21 5 - 6 5 , 199.5. 2. Beck RL: Redirecting the blaming in marital psychotherapy. Clin SOCWork J 15:148-158, 1987. 3. Berg K1, Jaya A: Different and same: Family therapy with Asian-American families. J Marital Family Ther 19:31-38, 1993. 4. Carter B, McGoldrick M: The Changing Family Life Cycle, A Framework for Fa~iily Therapy. New York, Gardner Press, 1988. 5. Cordova J, Jacobson N, Christensen A: Acceptance versus change interventions in behavioral couple therapy: Impact on couples in-session communication. J Marital Family Therapy 24:437455, 1998. 6. Dattilio F, Padesky C: Cognitive Therapy with Couples. Sarasota, FL, Professional Resource Exchange, 1990. 7. Gottman J, Notarins C, Gonso . I , Markman H: A Couples Guide to Communication. Champaign, IL, Research Press, 1976. 8. Greenspan R: Marital therapy with couples whose lack of self-sustaining function threatens the marriage. Clin Soc Work J 21:395404, 1993. 9. Guerin PP, Fayu L, Burden S, Kautto G: The Evaluation and Treatment of Marital Conflict. New York, Basic Books, 1987. 10. Gurman A, Kriskern D: Handbook of Family Therapy. New York, Brunner/Mazel, 1981, I I . Hugen B: The effectiveness of a psychoeducational support service to families of persons with a chronic mental illness. Res SOC Work Pract 3:137-154, 1993. 12. Marley J: Content and context: Working with mentally ill people in family therapy. Soc Work 37:412-417, 1992. 13. Molta D: Bipolar disorder and the family: An integrative model. Family Process 32:409423, 1993.