1. FAMILY THERAPY
Presented by: Deepanwita Roy
M.Phil 2nd year, Department of Clinical Psychology, University of Calcutta
2. Introduction
Family theory is a special theoretical and clinical orientation that views human behaviour
and psychiatric disturbances in their interpersonal context(Lansky 1989).
Interventions are designed to effect change in the family relationship system rather than in
the individual (Bell 1975; Minuchin 1974a; Olson 1970; Shapiro 1966).
Any symptom can be viewed simply as a particular type of behaviour functioning as a
homeostatic mechanism that regulates family interactions (Jackson 1965; Minuchin et al.
1975).
A person’s problems cannot be evaluated or treated apart from the context in which they
occur and the functions that they serve. This notion further implies that an individual cannot
be expected to change unless the family system changes (Haley 1962).
3. Goals
Family therapy as a psychotherapeutic modality has the following goals (Steinglass 1995):
1. Exploring the interactional dynamics of the family and its relationship to
psychopathology
2. Mobilizing the family’s internal strength and functional resources
3. Restructuring the maladaptive interactional family styles
4. Strengthening the family’s problem-solving behaviour
4. Emergence of Family Therapy
Prior to family therapy movement, psychiatrists and psychoanalysts focused on patient’s
already developed psyche and downplayed current outside detractors.
The expansion of psychoanalytic theory and ego psychology encouraged the belief that
symptoms were both embedded in the personality and emerged from adaptation to the family
environment.
The practice of treating psychological problems in the context of the family did not actually
begin until the mid 1950’s.
Therapists began to explore the dynamics of family life after World War II.
Important observation showed, how some of the battle-torn veterans readjusted after
returning to their families; whereas, on the other side, many seriously ill patients did not
respond to, or regressed, after individual treatment, when they returned to their home
environment.
5. Models of Family Therapy
There are various models of family therapy which uses different techniques in the therapeutic
process. These are stated below:
Structural Family Therapy
Strategic Family Therapy
Systemic Family Therapy
Psychodynamic approach including Object Relations Family Therapy
Trans-generational Family Therapy
Cognitive-Behavioural Family Therapy
Experiential Family Therapy
6. Structural Family Therapy
• SFT is based on organismic model, which looked at the world as an organization or system
and analyzed the relationships within that system.
• SFT is based on ‘systems theory’ that was developed at the Philadelphia Child Guidance
Clinic, under the leadership of Salvador Minuchin.
• The model’s distinctive features are its emphasis on structural change as the main goal of
therapy, which acquires preeminence over the details of individual change, and the attention
paid to the therapist as an active agent in the process of restructuring the family. It deals
with the maintaining factors of psychopathology rather than causes.
As Minuchin (1974) describes his viewpoint: “In essence, the structural approach to families is
based on the concept that a family is more than the individual bio-psychodynamics of its
members. Family members relate according to certain arrangements, which govern their
transactions. These arrangements, though usually not explicitly stated or even recognized, form
a whole—the structure of the family. The reality of the structure is of a different order from the
reality of the individual members.” (p. 89)
7. Theoretical Concepts:
Systems Theory: The three postulates of systems
theory—
■ Circular Causation (causation is circular):
Behavioral view of behavior linear causality is
found whereby A’s behavior leads to the behavior
of B and the latter leads to the behavior of C.
family systems view behavior, causality goes in
multiple directions.
■ Equi-potentiality (every part of a system
maintains the other): There are many pathways of
reaching a configuration within a system (a
particular pathway does not matter). End states
reached through different pathways are equivalent.
■ Complementarity (every behaviour is the
complement to every other): Understand the
matrix of the family relations in order to
understand the behaviour of one member.
Individuals’ability to change/ grow/ improve are
influenced by the ability or willingness of others in
the family to allow this change or growth to occur.
■ Homeostasis: SFT holds that the system, while
slowly changing and becoming more complex,
can, nevertheless, be seen as having a steady state,
a systemic homeostasis. Transforming the system’s
homeostasis is the goal of therapy—the
dysfunctional homeostasis is seen as maintaining
the difficulties.
■ Importance of the Contemporary Context: The
third fundamental concept of SFT is the notion that
the problem is maintained by the contemporary
social context—the family, the extended family,
friends, agencies, and any other social or physical
forces that impinge on the client and family.
8. ■ Structure:
– The fourth theoretical underpinning of
SFT is the concept of structure.
– As defined by Minuchin (1974a),
“family structure is the invisible set of
functional demands that organizes the
ways in which family members
interact.”
– An operational definition of structure
shows structure as the proximity and
distance between members in a system.
– Stemming from the concept of structure
is the concept of boundaries.
Boundaries describe the patterned
transactions between members of a
system to the exclusion of others.
9. Diagrammatic representations of various
aspects of SFT (Minuchin) Boundary
A family with clear or open boundary among the family members can be represented as
follows:
Father Mother
- - - - - - -- - - -- - - - - - - - - - - -
Child
Boundary Pathology: Having a diffused boundary among the family members, an enmeshed
relationship with each other is present in the family
Father Mother
…………………………………
Child
10. A coalition:
Mother Father
1st Daughter Son
2nd Daughter
Detouring conflict: Father Mother
Child
Alliances:
• A clear and friendly alliance Husband Wife
• An enmeshed or over- involved affiliation Mother Son
• A weak or unknown affiliation Father …………………….. Daughter
Conflict:
Sister Brother
11. PATHOLOGIES ACCORDING TO THE STRUCTURAL THEORY:
1. Pathology of alliance:
Cross generational coalition/ pathology of hierarchy
Mother Son Father
Conflict Detouring
Mother Father
Child
2. Pathology of Triangle
a) Triangulation: Mother Father
Child
b) Conflict Detouring (Attacking) (same as before)
12. c) Conflict Detouring (Supportive) Mother Father
Child
d) Parent Child Coalition Mother Father
Child
■ Techniques used:
Enactment:
• Enactment refers to the construction of an interpersonal scenario during the session in which a
dysfunctional transaction among family members is played out.
• The therapist is in the position of observing the family members’ verbal and nonverbal ways of
signalling to each other.
• The therapist can then intervene in the process, increasing its intensity, prolonging the time of the
transaction, introducing other family members, initiating alternative transactions, and in general
introducing experimental probes.
• The therapist can have the family enact “changed” transactional patterns during the therapy session that
can then serve as a template for the functional interactions outside the therapy.
13. Use of Self:
• In SFT, the therapist acknowledges that the self is an essential ingredient in the therapeutic
process.
• The therapist uses himself or herself as a tool for producing therapeutic change.
Joining:
• Joining is the central technique of entering the family system in order to create the new system, the
therapeutic system.
• There are a number of different positions the therapist can utilize in joining with the family,
including the close position, the median position, and the disengaged position.
Regulating Intensity:
• Intensity involves the therapist’s selective regulation of the degree of impact of the therapeutic
message.
• Family members have developed, through time, their preferred patterns of transaction and the
explanations necessary to defend their preference.
• Intensity can be achieved by increasing the affective component of a transaction, by increasing
the time in which family members are involved in such transactions, or by using frequent repetition
of the same message in different transactions.
• Regulating the degree of therapeutic intensity according to the feedback from the family is one of
the structural family therapist’s most powerful tools.
14. Constructions:
• The construction of new interpretive frameworks is an important feature of structural therapy. There
is a matching between the belief systems and the transactional patterns of families; therefore,
changes in one are reflected as modifications in the other.
• Construction is the therapist’s organization of this data in such a way that it provides the family
members with a different framework for experiencing themselves and one another.
• This new reality also has alternate solutions.
• The goal is not only to get people to think differently about their problems but also to help shepherd
them into interacting differently as a result of the new construction.
Use of Paradox:
• Paradox is a construction in which the family truth is embedded in a larger truth that contradicts it.
The result is a conflict between truth and truth that the therapist organizes to confuse family
members into a search for alternatives.
• The structural family therapist uses paradox relatively infrequently. The belief is that we do better if
we develop a collaborative relationship with the family.
Education:
• Education is an intervention on the cognitive level in which the therapist conveys a model of
normative family functions based on the therapist’s experience and axioms.
• Education differs from construction in that constructions are idiosyncratic in regard to the
individual family situation, whereas education deals with generic issues of family functioning.
• It includes notions such as the meaning and importance of boundaries, optimal functioning in
developmental stages, and transitional crises in family development.
15. Boundary Making:
• Boundary making is an essential concept of SFT and distinguishes it from other therapies.
• Boundary making is the process by which the therapist controls membership of family members in
a subsystem.
• It may be done by increasing proximity and experimentation among subsystem members with the
exclusion of others (making boundaries), or by facilitating participation of subsystem members with
other family and extrafamilial subsystems (diffusing boundaries).
Unbalancing
• Unbalancing is a method of disrupting an entrenched family hierarchical organization.
• “Steady state” (homeostasis) is the capacity of a system (biological or social) to maintain its
equilibrium within a certain functional range.
• Through unbalancing, the therapist introduces disequilibrium.
• Unbalancing refers to the therapist’s use of self as a member of the therapeutic system to
disequilibrate the family organization by joining and supporting an individual or family subsystem
at the expense of other family members.
16. Strategic Family Therapy
It is a therapeutic process where the therapist initiates what happens during therapy, designs a specific
approach for each person’s presenting problem, and where the therapist takes responsibility for
directly influencing people.
Strategic therapy offers an active, straightforward set of therapist interventions aimed at reducing or
eliminating the presenting set of family problems or behavioral symptoms.
It has derived from the work of Palo Alto research group projects of 1952-1962 on family
communication.
The defining characteristics of Strategic Family Therapy are:
1. A focus on current family communication patterns that serve to maintain a problem.
2. Treatment goals that derive from the problem/ symptom presented.
3. A belief that change can be rapid and does not require insight into the causes of the problem;
4. The use of resistance to promote change by applying specific strategies.
17. There are 3 types of Strategic Family Therapies. They are:
Strategic/Problem-Solving Therapy:
A primary feature of the strategic/problem-solving model is that the therapist takes the main
responsibility to set goals and create a plan that will result in the dissolution of the client’s
problem (Haley 1967, 1977, 1980b).
Brief Strategic/Interactional Therapy:
This model pays little attention to determining historical factors, Unlike “joining” in the problem-
solving model, which involves social talk, the interactional model holds that the client and
therapist join around solving the problem. A therapist must accept a role that is less dramatically
helpful.
Solution-Focused Therapy:
The solution-focused therapist assumes that clients have the solution to their problem within
them. The purpose of the therapy is to focus on how the client would know that the problem is
solved and on what the client is already doing that is useful and should be continued or
increased. The intention of working in this manner is to create a collaborative relationship
between therapist and client.
18. Systemic Family Therapy
Systemic therapies originated in Milan, Italy in the 1970s and 1980s and the Milan School of
Family Therapy was established by Mara Selvini-Palazzoli.
It conceptualizes family problems as being maintained by homeostasis, or a tendency to resist
change.
The Milan Group see the pathology to be arising out of systems that operate on the basis of
epistemological errors, i.e., the family members fail to see the circular connections to their
behavior, have a linear view of problems, see themselves having unilateral control over one
another and believe that there is an objective reality, e.g., ‘I am correct, you are wrong’ (Dell,
1985, p.4).
19. Some of the Techniques used:
Positive connotation: It is a form of reframing the family’s problem-maintaining behavior in which
symptoms are seen as positive or good because they help maintain the system’s balance and thus
facilitate family cohesion and well-being. It prepares the family for forthcoming paradoxical
prescriptions.
Hypothesizing: It is an assessment tool through which the therapist begins an exploration into the
family system and invites the family to join him/her in the investigation. Hypotheses must be systemic.
Circularity: It refers both to the attributes of member-to-member interactions and to the form of
interactions between the therapist and the family.
Neutrality : Attitude of the therapist toward the hypotheses generated in treatment. It has been
replaced by ‘curiosity’.
The treatment process has the following stages:
1. Constructing a working hypothesis
2. Exhibiting a therapeutic stance of neutrality
3. Using circular questioning as both an assessment and therapeutic technique
4. Working with a team to monitor the process
5. Identifying the labels used by the family
6. Identifying openings or themes to be explored
7. Using positive connotation for problematic behaviors
8. Using an end-of-session intervention
20. Psychodynamic Family Therapy
Contemporary psychodynamic and psychoanalytic approaches to family therapy share the
common view that the family is a social unit with interpersonal rules. The family and its
members can be best evaluated when the family is examined as a whole.
Some of the theoretical concepts are:
Transference: It is a regressive phenomenon by which unconscious infantile and childhood
conflicts are gradually and progressively mobilized and re-experienced in current life situation
inside and outside of therapy. The various transference reactions of patients described by object
relation therapists as:
• Contextual transference: It refers to the therapeutic situation, management of the
therapeutic situation, and the patient’s expectations about the therapy,
• Focused transference: The second form of transference, focused transference, consists
of the patient’s focused projections onto the therapist based on the early experiences.,
and
• shared contextual transference The third type of transference, shared contextual
transference, reveals the couple’s difficulties with the holding situation.
21. Countertransference: Countertransference arises out of the therapist’s identification of himself
with the patient’s internal objects (Racker 1981). Behaviors such as distancing, unempathic
interpretation, taking sides and reversal, reverting to dyadic or individual therapy, simplification of
the issues, preoccupation and rationalized emotional withdrawal, shaming the patient, or
impulsive attempts to control one of the spouses are some of the ways countertransference is
exhibited.
Resistance: The common forms of resistance in family therapy include avoiding conflictual topics,
scapegoating, becoming depressed to avoid expression of anger, refusing to consider one’s own
role in dysfunctional interactions, seeking individual sessions or individual treatment, keeping
secrets, threatening to leave treatment or changing therapists, and acting-out.
Socially Shared Psychopathology: The concept of “socially shared psychopathology” is the end
result of a number of interpersonal psychological mechanisms such as projective identification
and delineation. Projective identification is an interpersonal defense mechanism shared by two or
more people based on a shared fantasized object relationship.
Holding Environment: The concept of holding environment developed by Winnicott refers to a
quality and characteristic of interaction between the mother and infant. The holding environment
produced by the mother provides safety, constancy, and protection for the infant. It also would
provide a precise reflection of the infant’s experience and gestures to him or her that can facilitate
growth as well as allowing temporary regressions.
22. Bonding and Attachment: The presence of an available and responsive attachment figure gives a
person a pervasive feeling of security and encourages him or her to value and continue the
relationship.
True Self/False Self: The concepts of true and false self proposed by Winnicott (1958) are rooted in
his view of early development. The “true self” is based on the child’s experience of nurture by a “good
enough mother” who appreciates the importance of need satisfaction in the infant.
Separation-Individuation Theory: In the first three years of life, the child goes through a succession
of phases by which he or she attempts to arrive at a differentiated sense of self and the mother
(object). A decisive period in the separation-individuation process is the “rapprochement phase, in
which the infant is pulled between two forces: the need to stay close to the caretaker while being
pushed to function autonomously. This results in the “rapprochement crisis” that reaches its height in
the second half of the second year of life.
Therapeutic techniques:
Listening: attentively to listening to what the client and the family has to say regarding the ongoing
problems and their outcomes, noting out the various underlying dynamics within the family as a
whole.
Empathy: taking up an empathetic position with respect to the family.
Analytic Neutrality: understanding the contents of the problems itself without worrying on solving
the problems.
Interpretations: Clarifying hidden aspects of experience and interpreting the experiences for a
better understanding so as to unfold the dynamics better.
23. Trans-generational Family Therapy
Transgenerational approaches offer a psychoanalytically influenced, historical perspective to
current family living problems by attending specifically to family relational patterns over
decades.
Advocates of this view believe current family patterns are embedded in unresolved issues in
the families of origin.
How today’s family members form attachments, manage intimacy, deal with power and resolve
conflict, and so on, may mirror to a greater or lesser extent earlier family patterns.
Bowen Family Systems Therapy: Bowen hypothesized that mentally ill individuals were caught
up in patterns of family fusion or undifferentiated ego mass such that they were symptom bearers
for the family.
The Emotional System: The emotional system is not equivalent to feelings. People only feel
the more conspicuous or superficial aspects of their emotional system functioning. They do not
feel emotional reactivity such as cell division or DNA repair, but people do feel the emotional
system working when they react to the death of close kin or the physical injury of others.
Feeling systems, as opposed to emotional systems, have evolved in species with fairly
complex brains (MacLean 1989).
24. Life Forces for Fusion and Differentiation: One force is for fusion, which is manifest in people
overtly and covertly pressuring each other to think, feel, and act in certain ways. The opposing
force is for differentiation, which is manifest in people thinking, feeling, and acting for themselves.
Anxiety disturbs the fusion-differentiation balance. The higher individuals’ basic levels of
differentiation, the greater their capacity to be in emotional contact with others without fusing with
them, even if anxiety is high.
The Triangle: A triangle is an emotionally fused three-person system. The characteristics of a
triangle vary depending on the level of anxiety. Triangles are the smallest stable emotional units,
since two-person systems tolerate little anxiety before involving a third person. A triangle can
contain much more anxiety than a two-person system. One triangle may get sufficiently “saturated”
with anxiety that the anxiety spreads to other triangles creating “interlocking triangles. Anxiety
activates mechanisms or “patterns of emotional functioning” in a relationship to manage the
anxiety. Each pattern manages anxiety in a different way.
Patterns of Emotional Functioning
– Emotional distance
– Emotional conflict
– Dominant-submissive
– Over-involvement with a child
The Scale of Differentiation
– Basic levels of their parents
– Level of anxiety in their nuclear family while growing up
– Dominant patterns of emotional functioning in their nuclear family
25. Cognitive Behavioral Family Therapy
Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that addresses dysfunctional
emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-
oriented, explicit systematic procedures.
Conflict in families can be lessened by maximizing use of principles of reinforcement by family
members. Working on distorted cognitions can be done with families with parents who have
triangulated their conflicts onto the child.
Dattilio (2001) noted that cognitive behavioral family therapy integrates a systemic perspective
clearly appreciating circularity and reciprocity of relationships.
Therapeutic Goals:
■ The goals are typically to identify and monitor cognitions, expectations, beliefs and behaviors
that are related and accompanied to negative feelings and to identify those which are dysfunctional
or simply useless and replace them with more useful ones;
■ To help the family see how the maladaptive behavior originates and help families accelerate
positive behavior;
■ To help the family see the connection between thoughts, feelings and behaviors;
■ To help the family see the negative consequences of the behaviors and to help them change
the thoughts, which will then address the feelings and ultimately the behavior.
26. Techniques of cognitive Behavioral family therapy:
Self-monitoring: Self-monitoring requires patients to observe and record specific
physiological, cognitive, behavioral, emotional, and interpersonal processes.
Self-instruction: Simply, self-instructional techniques target thought content (e.g. automatic
thoughts) and cognitive processes (e.g. cognitive distortions).
Rational analysis: In rational analysis, the patient collects the data and then crafts
conclusions and judgments, which make sense of new information
Behavioral enactment: The therapists organize and set up the experiments or situations
which will elicit the dysfunctional patterns.
Currently, cognitive and behavioral approaches are having a significant impact in four distinct
areas are behavioral couples therapy, behavioral parent training, functional family therapy and
conjoint treatment of sexual dysfunction.
27. Experiential Family Therapy
Experiential therapy blends therapies like Gestalt and family therapy. The purpose is to enact or
reenact the emotional climate of the family of origin and/or other past and present significant
relationships in a person's life.
In re-experiencing these events and relationships, one is able to release and express the emotions
that may have been blocked and repressed.
Theoretical Key Concepts: this form of therapy puts emphasis on freedom of individuals and
emotional experiences. It deals with ‘here-and-now’ experiences.
Gestalt family therapy (Kempler, 1973; Kaplan and Kaplan, I978), transactional analysis family
therapy (Erskine, I 982) and transactional analysis-Gestalt combinations (McClendon and Kadis,
1983).
Goals of Experiential Family Therapy include:
■ maintaining personal integrity, expanding experience, liberating affect and impulses,
■ putting little focus on presenting problem,
■ promoting communication and interaction.
■ The Primary Techniques include: Family Sculpting, Family Puppet Interviews, Family Art Therapy,
Conjoint Family Drawings, Animal Attribution, Play Therapy Techniques, Role-Playing and Gestalt
Therapy.
28. SPECIAL POPULATIONS IN FAMILY
THERAPY:
Working with single- parent families
Working with remarried families
Working with substance- related disorders, domestic violence, and
child abuse in families
29. Working with single- parent families
Several family therapy approaches work well with single- parent families (Westcot & Dries,
1990).
Six family theories most often employed are: structural, strategic, solution-focused, Bowenian,
experiential, and narrative.
Structural family therapy appears to be popular because it deals with common concerns of
single- parent families such as structure, boundaries, and power (Minuchin & Fishman, 1981).
The interventions seek to restructure or redefine the family systems (Minuchin, 1974).
Role of the therapist:
To deal with boundaries, hierarchies, and engagement/ detachment.
Must lay aside personal biases/ prejudices
Must deal with emotional volatility of the family
Must foster inner resources and support groups for family members.
30. Working with remarried families
Issues within remarried families include:
Resolving the past
Alleviating fears and concerns about step family life
Establishing and reestablishing trust
Becoming emotionally/ psychologically attached to others
Approaches to treating remarried families:
Help families recognize and deal appropriately with old loyalties and new ties
Help families become involved constructively with significant others, such as former
spouse or new children
Help families develop their own rituals and traditions
Further apply structural, strategic, Bowenian and experiential family therapy to deal with
issues such as past history, boundaries, structure and feelings.
31. Working with substance- related disorders,
domestic violence, and child abuse in families
Engaging substance-related disorder families in treatment:
It is necessary to engage the least engaged as well as the most engaged member of the
family.
Treatment must include issues such as relapse, the environment, and intrapersonal (i.e.
emotional) and interpersonal (i.e. social) relations.
Domestic violence and families:
Usually the assessment is complicated by legal and psychological barriers
Hence, family therapists must use conjoint family therapy, intimate justice theory, and
educational methods, for example, CBT.
Child abuse and neglect in families:
It includes physical, sexual, and psychological abuse as well as neglect and
abandonment.
It is long lasting and damaging
And thus, complicated and involves legal, developmental, and psychological issues.
