FAMILY THERAPY

Historical Background

In understanding family therapy as it is now, it will be helpful to learn about the contribution of child
guidance clinics and marriage counseling in helping families cope with problems. From both theoretical and in-
depth perspectives, Freud and other psychoanalysts contributed to the understanding of families through
their emphasis on the impact of early childhood events on adulthood and through their own
psychotherapeutic work with children.

General systems theory- It examines the interactions and processes of parts of a whole in areas such as
engineering, biology, economics, politics, sociology, psychology, and psychotherapy.

Family therapy is psychotherapeutic treatment of the family to bring about better psychological functioning.

Family systems - therapy is a type of family therapy that concentrates on the interactions of family members
and views the entire family as a unit or system.
- Treatment is designed to understand and bring about change within the family structure.

This theory will focus on four aspects: Each of the four sections describes how theorists understand the
family, their goals for treatment, and their treatment approach.
- Intergenerational,
- Structural,
- Strategic, and
- Experiential.

Intergenerational approach of Murray Bowen examines the impact of the parents’ interaction with their own
family of origin as it affects their interaction with their children.

Salvador Minuchin’s structural approach is concerned with how family members relate to each other in the
therapy hour and at home.

Jay Haley’s strategic approach is directed at bringing about change in symptoms.

The experiential family system therapies emphasize the unconscious and affective processes of families and
therapists in their work.

Early Approaches to Family Counseling

- Formal marriage counseling has been available since the 1930s.
- Before that time, informal counseling was probably provided by friends, doctors, clergy, and lawyers.
- The first centers for marriage counseling were opened in Los Angeles by Paul Popenoe and in New York
City by Abraham and Hannah Stone (Goldenberg & Goldenberg, 2008).
- By the 1940s, 15 centers devoted to marriage or family issues had been established to help families in
the community. These clinics dealt with problems such as infidelity, divorce, child raising, financial
problems, communication problems, and sexual incompatibilities.
 - In general, most marital therapy was brief and problem focused, taking into consideration the
personality and role expectations of each member of the couple as well as their communicating and
decision-making patterns (Cromwell, Olson, & Fournier, 1976).
- In the 1950s, conjoint therapy, in which both members of the couple were seen together by one
therapist, became more common. As marriage counseling developed, it focused more and more on
attending to and working with the marriage relationship and less on the individual personality issues of
each client.
- During the 1930s and 1940s and into the 1950s, problems with children were often left to child
guidance clinics,although they might be discussed in marriage counseling (Mittelman, 1948).
- Usually the parents were treated separately from the children. Often mothers were seen as the cause
of the problem, with little attention given to fathers.
- The focus was primarily on treatment of the child and secondarily to help the mother deal with
negative feelings that may affect child raising and to help her learn new attitudes or approaches.
- Levy (1943) wrote about the negative impact of maternal overprotection on children, and Fromm-
Reichmann (1948) was concerned about the impact of the schizophrenogenic mother (dominating,
rejecting, and insecure) on children.
- In the 1950s, there was a shift from blaming parents for children’s problems to helping parents and
children relate better to each other. For example, Cooper (1974) addressed positive goals of parental
involvement so that progress with the child in therapy could develop and parents could make changes
in the child’s environment to help the child improve.

Psychoanalytic and Related Influences on Family Therapy

- Sigmund Freud treated both children and adolescents and attended to processes related to early
childhood development in all of his patients.
- Alfred Adler, who observed the development of social interest within the family and initiated child
guidance clinics in Vienna,.
- Harry Stack Sullivan (1953) was concerned with not only intrapsychic factors but also interpersonal
relationships within the family and with others. Some of his observations had a direct influence on
later family therapists.

Nathan Ackerman- a person considered the initiator of family therapy and work with families as a unit.
- A child psychiatrist who was trained in psychoanalysis, he initially used the traditional model in which
the psychiatrist saw the child and the social worker saw the mother.
- In the mid-1940s, however, he started to see the entire family for both diagnosis and treatment.
- He was aware of conscious and unconscious issues within the individual and the family, as well as
issues that affected the family as a whole.
- As a result, he often attended to nonverbal cues such as facial expression, posture, and seating
arrangements as a way of assessing family problems.
- In his therapeutic approach, Ackerman was open, honest, and direct, encouraging families to share
their own thoughts and feelings as he did.
- In his work with families, he became emotionally involved with the family while at the same time
looking for unconscious themes (Nichols, 2008).
- Many family therapists were drawn to his engaging style and his active approach to therapy. However,
his writings (Ackerman, 1966a, 1966b) do not provide a clear, systematic approach for therapists who
wish to follow his method.

The Study of Communication Patterns in Families with Members Having Symptoms of Schizophrenia

Double bind
 - Work of Palo Alto, Bateson, Jackson, Haley, and Weakland (1956) studied how families with children
who had symptoms of schizophrenia functioned and maintained stability.
- They observed the double bind, in which a person receives two related but contradictory messages.
One message may be relatively clear, the other message unclear (often nonverbal), creating a “no-win”
paradox.
- Bateson et al. (1956) give a classic example of a mother giving a nonverbal message that says “go
away,” followed by a message that says “come closer, you need my love,” and then “you’re interpreting my
messages in the wrong way” (Goldenberg & Goldenberg, 2008).
- Bateson and his colleagues believed that if individuals were continually exposed to these types of
messages, they would eventually lose the ability to understand their own and others’ communication patterns
and would develop schizophrenic behavior.

Marital schism and marital skew

- Lidz and his colleagues found unusual patterns of family communications between parents and their
children (Lidz, Cornelison, Fleck, & Terry, 1957).
- They reported two particular types of marital discord in families with members with schizophrenia:
marital schism and marital skew.
- In both of these situations, but particularly in marital schism, a child is in a bind; by pleasing one
parent, he might displease the other.
Marital schism- parents preoccupied with their own problems tended to undermine the worth of the other
parent by competing for sympathy and support from the children. For example, if the father did not value the
mother, he would be afraid the child would grow up like the mother, and so the mother would be devalued.

Marital skew- the psychological disturbance of one parent tends to dominate the home. The other parent,
accepting the situation, implies that the home is normal and that everything is fine, thus distorting reality to
the children.

Pseudomutuality
- There is an appearance of open relationships that serves to conceal distant relationships within the
family (Wynne, Ryckoff, Day, & Hirsch, 1958).
- Roles are used to keep harmony in the family rather than have open interactions, family members may
relate in limited or superficial ways to each other and to other people.
- Lyman Wynne and his colleagues observed that in families of children with symptoms of schizophrenia,
there was often a conflict between the child’s need to develop a separate identity and to maintain
intimate relationships with troubled or emotional family members.
- He heightened emotional expression in families coping with schizophrenia contributes to problems
within the family (Wahlberg & Wynne, 2001). Thus, the interaction between individuals, not the
person’s own psychological functioning, is seen as having a role in the development of schizophrenia.
- The findings of Bateson, Lidz, and Wynne and their colleagues all relate to communication patterns
that the participants are unaware of and that create stress in marriages and in child raising.

General Systems Theory

- Von Bertalanffy’s (1968) work in biology and medicine explored the interrelationships of parts to each
other and to the whole system.
- When his general theoretical approach is applied to family therapy, a family cannot be understood
without knowing how the family functions as a whole unit.
- From a systems theory perspective, each family is a part of a larger system, a neighborhood, which is
again a part of a larger system, a town, and so forth.
 - Individuals are wholes that comprise smaller systems, organs, tissues, cells, and so forth. If any part of
a system changes, the whole system reflects a change.
- Important concepts in understanding general systems theory are feedback and homeostasis, which
deal with ways in which systems and their units function.

Feedback
- refers to the communication pattern within the units of a system.
- There are two basic patterns of communication: linear and circular.

Linear approach- communication occurs in a single direction.

Circular feedback- each unit may change and thus affect any of the other units.

Homeostasis- systems have a tendency to seek stability and equilibrium.

- An example of homeostasis is a thermostat used to regulate temperature so that a house does not
become too hot or cold.
- The process by which this equilibrium is achieved is feedback from units within the system.

There are two basic types of feedback: negative and positive. ((Note that in systems theory the meanings of
negative and positive feedback differ from their common meanings of “negative” and “positive feedback.”

positive feedback- change occurs in the system

negative feedback- equilibrium is achieved

For example, if Helen’s father talks with Helen about why she is late and works with her to reduce the
behavior that causes disequilibrium, negative feedback affects the family system. If instead he gets angry and
yells at her, she may stay out late more often, and the system is changed through the use of positive feedback
processes. In this brief example, positive feedback is seen as having an unhelpful impact on a family.
Depending on the nature of the change that occurs, positive feedback may also be helpful.

FOUR APPROACHES TO FAMILY SYSTEMS THERAPY

 Bowen’s intergenerational approach,

 Minuchin’s structural theory
 Haley’s strategic approach
 Satir’s and Whittaker’s experiential approaches

1. Bowen’s Intergenerational Approach

- Based on the individual’s ability to differentiate his own intellectual functioning from feelings.
- This concept is applied to family processes and the ways that individuals project their own stresses
onto other family members.
- He examined the triangular relationship between family members such as the parents and a child.
- How individuals cope with the stress put on them by the way other family members deal with their
anxieties is an important issue for Bowen.
- He is particularly concerned with the ways children may distance themselves emotionally, and also
physically, from their families.
- How families can transmit over several generations psychological characteristics that affect the
interaction of dysfunctional families.
EIGHT CONCEPTS FORM THE CORE OF SYSTEM OF FAMILY THERAPY

1. Differentiation of self
- Being able to differentiate one’s intellectual processes from one’s feeling processes represents a clear
differentiation of self.
- The importance of awareness of feelings and thoughts, particularly the ability to distinguish between
the two.
- In a family conflict, people who are able to differentiate their emotions and intellects are able to stand
up for themselves and not be dominated by the feelings of others, whereas those whose feelings and
thoughts are fused may express a pseudoself rather than their true values or opinions.

2. Triangulation
- When there is stress between two people in a family, they may be likely (Bowen, 1978) to bring
another member in to dilute the anxiety or tension.
- Bowen believes that when there is stress in the family, the least-differentiated person is likely to be
drawn into the conflict to reduce tension (Goldenberg & Goldenberg, 2008). Triangulation is not
limited to the family, as friends, relatives, or a therapist may be brought into a conflict.
- For Bowen (1975), a two-person system was unstable, and when there is stress, joining with a third
person reduces the tension in the relationship between the original two people.

3. Nuclear family emotional systems

- The family as a system—that is, the nuclear family emotional system—is likely to be unstable unless
members of the family are each well differentiated.
- Bowen (1978) believed that spouses are likely to select partners with similar levels of differentiation. If
two people with low levels of differentiation marry, it is likely that as a couple they will become highly
fused, as will their family when they have children.

4. Family projection process

- When there are relatively low levels of differentiation in the marriage partners, they may project their
stress onto one child.
- In general, the child who is most emotionally attached to the parents may have the least
differentiation between feelings and intellect and the most difficulty in separating from the family
(Papero, 1983, 2000).
- For example, a child who refuses to go to school and wants to stay home with his parents can be
considered to have fused with his parents. How intense the family projection process is depends on
how undifferentiated the parents are and on the family’s stress level (Bitter, 2009). The “problem
child” can respond to the stress of his undifferentiated parents in a variety of ways.

5. Emotional cutoff
- When children receive too much stress because of over involvement in the family, they may try to
separate themselves from the family through emotional cutoff.
- Adolescents might move away from home, go to college, or run away. For younger children and
adolescents, it may mean withdrawing emotionally from the family and going through the motions of
being in the family.
- A child experiencing an emotional cutoff may go to her room not so much to study but to be free of the
family conflict.

6. Multigenerational transmission process

- Bowen (1976) looked not just at the immediate family but also at previous generations (Kerr, 2003).
 - Naturally, Bowen recognized that spouses do not always marry at their own exact level of
differentiation. In the concept of the multigenerational transmission process, the functioning of
grandparents, great-grandparents, great-aunts, great-uncles, and other relatives may play an
important role in the pathology of the family.

7. Sibling position
- Bowen believed that birth order had an impact on the functioning of children within the family.
- Relying on the work of Toman (1961), he believed that the sibling position of marriage partners would
affect how they perform as parents.

8. Societal regression
- If there are stresses on societies, they are more likely to move toward undifferentiation.
- Examples of stresses could be famine, civil uprisings, or population growth. To extend Bowen’s model
to societies, leaders and policymakers should distinguish between intellect and emotion when making
decisions and not act on feelings alone.

Therapy Goals

- Bowen was interested in the impact of past generations on present family functioning.
- As he set goals in working with families, he listened to the presenting symptoms and, even more
important, to family dynamics as they relate to differentiation of family members and to triangulation.
- he sought to help families reduce their general stress level and to find ways to help family members
become more differentiated and meet their individual needs as well as family needs (Kerr & Bowen,
1988).

Techniques of Bowen’s Family Therapy

- evaluation period precedes therapeutic intervention
- Taking a family history is aided by the use of a genogram - diagram of the family tree that usually
includes the children, parents, grandparents, aunts and uncles, and possibly other relatives.
- Bowen used interpretation of his understanding of intergenerational factors.
- Bowen (1978) saw himself as a coach, helping his patients analyze the family situation and plan
strategies for events that are likely to occur.
- he often focused on detriangulation - a way of changing patterns of dealing with stress.
a. Evaluation interview
b. Genograms
c. Interpretation
d. Detriangulation

Structural Family Therapy

- Developed by Salvador Minuchin, helps families by dealing with problems as they affect current
interactions of family members.
- Therapeutic approaches emphasize changing the nature and intensity of relationships within the family
both inside and outside the therapy session.

Concepts of Structural Family Therapy

- Focus on how families operate as a system and their structure within the system.
- attending to the organization of the family and the rules and guidelines family members use to make
decisions
 - Minuchin uses concepts such as boundaries, alignments, and coalitions to explain family systems.

Family structure
- refers to the rules that have been developed over the years to determine who interacts with whom.
- Structures may be temporary or long-standing.
- Being aware of family rules, and thus the structure, is important for therapists in determining the best
way to help dysfunctional families change. Within the family system are subsystems that also have
their own rules.

Family subsystems
- For a family to function well, members must work together to carry out functions.
- The most obvious subsystems are those of husband–wife, parents–children, and siblings.
Boundary permeability
- Permeability of boundaries describes the type of contact that members within family systems and
subsystems have with each other.
- A highly permeable boundary would be found in enmeshed families, whereas non-permeable or rigid
boundaries would be found in disengaged families.
- For example, if a seventh-grade child who had previously been performing well in school brings a note
home from a teacher saying that he is failing English, the child may be told by his father not to let this
happen again, to change his behavior, and that there will be no further discussion of this issue. In this
case, the boundaries are rigid and the family is relatively disengaged from the child.
- In an enmeshed family, the father, mother, brother, and sister may inquire about the child’s grades.
The siblings may tease, the father may be distressed, and the mother may check frequently during the
week to see if the child is doing his homework.

Alignments and coalitions

Alignments refer to the ways that family members join with each other or oppose each other in dealing with
an activity.

Coalitions refer to alliances between family members against another family member.

- Minuchin uses the term triangle more specifically than does Bowen to describe a coalition in which
“each parent demands that the child side with him against the other parent” (Minuchin, 1974, p. 102).
Thus, power within the family shifts, depending upon alignments and coalitions.

Goals of Structural Family Therapy

- Working in the present with the current family structure, structural family therapists try to alter
coalitions and alliances to bring about change in the family.
- To establish boundaries within the family those are neither too rigid nor too flexible.
- Supporting the parental subsystem as the decision-making system that is responsible for the family,
therapists work to help the family system use power in a way that functions well.

Techniques of Structural Family Therapy

1. Family mapping
- Minuchin uses diagrams to describe current ways that families relate.
- Maps of family interaction allow therapists to better understand repeated dysfunctional behavior so
that strategies for modification can be applied.
 2. Accommodating and joining
- Minuchin (1974) believes that it is important to join a family system and accommodate to its way of
interacting.
- By using the same type of language and telling amusing stories relevant to the family, he seeks to fit in.

3. Enactment
- instructing the family to act out a conflict, the therapist can work with problems as they appear in the
present rather than as they are reported.
- allows the therapist to understand the family’s coalitions and alliances and then to make suggestions
for changing the family system.

4. Intensity
- By repeating the message, changing the length of time of a particular interaction, or other means,
change can be facilitated (Minuchin & Fishman, 1981).
- For example, if parents are overprotective, the therapist may suggest that parents not nag the child
about his homework, not ask as many questions about school, and not monitor how his allowance is
spent.

5. Changing boundaries
- As the therapist observes the family interacting either in an enactment or in general presentation, the
therapist uses boundary marking to note boundaries in the family.
- therapists may rearrange the seating of the family members and change the distance between them.
- A creative way to address boundary issues is to use the Family Boundaries Game (Laninga, Sanders, &
Greenwood, 2008).

6. Reframing

Strategic Therapy

Concepts of Strategic Therapy

- Haley observes the interaction among family members, attending particularly to power relationships
and to the ways parents deal with power.
- Viewing relationships as power struggles, Haley (1976) is interested in understanding how relationships
are defined.
- a communication from one person to another is an act that defines the relationship (Haley, 1963).
- the concept of hierarchy, in which the parents are in a superior position to the children in terms of
making decisions and adhering to family responsibilities.
- he is concerned with family triangles such as those in which one parent is overinvolved with the child
and the other is underinvolved.
- What separates structural from strategic approaches is the attention given by strategic family
therapists to symptoms.
- For Haley, symptoms are an unacknowledged way of communicating within the family system, usually
when there is no other solution to a problem. For strategic therapists, the symptom is often a
metaphor (Madanes, 1981) for a way of feeling or behaving within the family.

Goals
- reduce anxiety must be stated in such a way that the therapist knows which family members are
experiencing anxiety, in what way, and in which situations.
Techniques of Strategic Family Therapy

1. Straightforward tasks
- By talking with the family and observing family boundaries and subsystems, the therapist will be able
to help the family accomplish its goals (Madanes, 1981).
- Before suggesting tasks, therapists should explore what the family has done to solve the problem so
they do not make suggestions that have been tried and failed.
- By examining what happens if the problem is not solved, then, family members are more likely to
appreciate the importance of doing something about the problem.
- Sometimes, however, straightforward tasks, whether they are metaphorical or direct, may not be
sufficient to bring about change.

2. Paradoxical tasks
- Basically, paradoxical suggestions are those that ask the family to continue the behavior for which they
are requesting help, but in such a way that whether they comply or not, positive change will result. In a
sense, the therapist is trying to get the family to decide not to do what they have been asked to do.
- Use of paradoxical directives takes experience and confidence on the part of the therapist, and they
are used only when the family resists straightforward suggestions.
- Papp (1980, 1984) has suggested three steps: redefining, prescribing, and restraining.

Redefine - The first step is to redefine the symptom in terms of the benefits it provides for the family. As
Goldenberg and Goldenberg (2008) suggest, anger can be called love, suffering can be seen as self-sacrifice,
and distancing can be used as a way of reinforcing closeness.

Prescribing- In prescribing the symptom, the family is encouraged to continue what they have been doing
because if they do not there will be a loss of benefits to the family.

In prescribing the symptom, the therapist must be clear and sincere in the rationale. When the family starts to
show improvement, the therapist tries to restrain the growth or change in order to keep the paradox working.

Experiential and Humanistic Family Therapies

- Experiential approach of Carl Whitaker
- Humanistic approach of Virginia Satir
- Both experiential and humanistic family therapists see dysfunctional behavior as the result of
interference with personal growth.
- For families to grow, communication between family members and self-expression of individuals must
both be open, while appreciating the uniqueness and differences between family members. In setting
goals for therapy, both therapist and the family take responsibility (Goldenberg & Goldenberg, 2008).

The Experiential Therapy of Carl Whitaker

- He saw theory as a hindrance in clinical work and preferred an intuitive approach, using the therapist’s
own resources.
- Characteristic of his approach is the use of countertransference (his own reactions to clients). Not only
do clients grow and change in therapy; so do therapists. Because clients and therapists affect each
other, each takes on the role of patient and therapist at various moments in therapy. This interaction
fosters the goal of interpersonal growth among family members (and therapists).
- Whitaker (1976) listened for impulses and symbols of unconscious behavior.
- Sometimes he responded consciously to feelings or family members’ ways of relating; at other times
he would be unaware of why he was responding the way he was.
 - He often suggested clients fantasize about an experience. This may lead to understanding the
absurdity of a situation.
- Situations are viewed in ways that emphasize choice and experience rather than sickness or pathology.
- Whitaker and Keith (1981) described the beginning, middle, and ending phases of therapy.

- Beginning phase, there is a battle for taking initiative in developing a structure, such as determining
who is going to be present at the therapy sessions.

- In the middle phase, Whitaker worked actively on family issues, bringing in extended family when
appropriate. To bring about change, he used confrontation, exaggeration, or absurdity. When he
picked up an absurdity in the patient, he built upon it until the patient recognized it and could change
her approach.

- The ending phase of therapy deals with separation anxiety on the part of the family (and therapist) and
the gradual disentanglement from each other’s lives.

- Whitaker’s style was marked by energy, involvement, and creativity.

The Humanistic Approach of Virginia Satir

- With individuals and families, she focused on developing a sense of strength and self-worth and
bringing flexibility into family situations to initiate change (McLendon, 2000; Nichols, 2008).
- An example is her outline for effective communication within the family (Satir, 1972): Use the first
person and express what you feel; use “I” statements that indicate the taking of responsibility, such as
“I feel angry”; family members must level with each other; and one’s facial expression, body position,
and voice should match.
- five styles of relating within the family (Satir, 1972):

 the placater- weak and tentative, always agreeing;

 the blamer, finding fault with others;
 the superreasonable, detached, calm, and unemotional;
 the irrelevant, distracting others and not relating to family processes;
 and the congruent communicator, genuinely expressive, real, and open.

- Satir always met with the entire family, helping them to feel better about themselves and each other.

Family life chronology

- in which the history of the family’s development was recorded.
- This chronology included how spouses met, how they saw themselves in relationship with their
siblings, and their expectations of parenting.
- The children were also included and asked to contribute by saying how they saw their parents and
family activities.

Family reconstruction
- an experiential approach including guided fantasy, hypnosis, psychodrama, and role playing.

Family sculpting
 - in which family members were physically molded into characteristic poses representing a view of
family relationships.

Integrative Approaches to Family Systems Therapy

- Distinctions between individual and family therapy are less definitive. Therapists may mix individual,
couple, and family sessions in treatment.
- There is currently a greater focus on use of concepts rather than theory. Thus, “differentiation”
(Bowen), “enactment” (Minuchin), and genograms may be used by therapists of many orientations.
Also, as integrative approaches emerge, no single one dominates. As will be shown in the research
section, research does not support one approach more than others. Typically, integrative approaches
are theoretically sound in that a rationale is given for using combinations of theories of family
therapies.

Theories of Individual Therapy as Applied to Family Therapy

- Psychoanalysis
- Adlerian Therapy
- Existential Therapy- therapists focus not only on the relationship between individuals but also on the
awareness that individuals have of themselves and their own being in the world
- Person-Centered Therapy- Family therapists may empathize not only with individual members of the
family but also with the relationship issues at hand. When not all family members are present for a
session, the therapist could also be empathic with an absent family member.
- Gestalt Therapy- help individuals in the family become aware of their patterns of interactions. They
may focus on sensations, listening, watching, or touching to achieve the awareness of boundaries so
that appropriate separation and integration can be achieved.
- Behavior Therapy- parents apply behavioral and experimental methods to change the behavior of the
identified patient. They may first establish a baseline of the child’s behavior they wish to change in
order to determine its nature and frequency.
- Rational Emotive Behavior Therapy- to help members see that they disturb themselves by their
irrational beliefs. By learning about their irrational beliefs and giving them up, family members find
that they can still have their wishes, preferences, and desires.
- Therapists often use disputing of shoulds and musts more than other family therapists using different
theories.
- Cognitive Therapy- They attend to the automatic thoughts and cognitive schemas of individuals so that
they can make therapeutic interventions.
- Reality Therapy- often observe the choice systems of different family members and how they interact
and connect with each other.
- Attention is paid not just to the shared feelings but also to the wants and values of each family
member.
- After an assessment of wants and needs, suggestions are made to focus on doing things together to
promote family harmony.
- Feminist Therapy- The approach is not on how to help the unfortunate woman who has been
mistreated by a “bad” man.
- feminist therapists look at political and social factors that provide insight into how family members
react to each other. The focus is not on attaching blame or rescuing people but on how gender and
power issues affect clients.