A family approach to psychological services

THE AMERICAN JOURNAL OF PSYCHOANALYSIS 35:317-328 (1975)

A FAMILY APPROACH TO PSYCHOLOGICAL SERVICES*

Irene Goldenberg and Herbert Goldenberg

Current thinking among some members of the psychological care-giving disciplines reflects dissatisfaction with traditional one-to-one forms of psychotherapy. Not only has individual psychotherapy been criticized as costly, lengthy, and not always effective, but it has been unavailable for large numbers of potential consumers. The current search for new ways of delivering psychological services (along with other health- related or human services), in order to reach a wider population in more appropriate ways, has opened up the possibility for expanding beyond traditional practices. Not only have new delivery systems been explored but also new insights have been developed regarding possible factors involved in the origin of psychologically disordered behavior. One such insight is that an individual's failure to cope with stress, either because that external stress is too great or persistent or because his or her internal adaptive resources are (perhaps temporarily) inadequate to the task, frequently can be traced to factors that operate currently in his or her family situation. Family therapy, then, becomes a vehicle for offering services to a whole system in need of repair.

Family therapy is a psychotherapeutic approach aimed at helping the family, as a functioning system, to interact in more constructive and mutually facilitating ways. More an orientation to viewing human problems in their context than representative of any single set of theoretical formulations, family therapy directs the family's attention to faulty, destructive, or pathological modes of family communication and interpersonal transactions for the purpose of changing the family system. In contrast to more traditional forms of individual psychotherapy, changes in the behavior of individual family members occur in family therapy as a result of system change, not vice versa. That is, family therapy is not simply treating individuals in a family context; rather, it assumes that it is the disordered family process that requires intervention and change, that it is the system that is faulty. In family therapy, the family itself is the functional unit requiring study and psychological service. The individual with the emotional problem or psychological symptoms is merely the/dent/f/ed pat~eat. His problem may be etiologically or dynamically obscure from the standpoint of individual study, but can often be made intelligible when viewed in the matrix of a family social system in disequilibrium.

Mental-health professionals have always been interested in their clients' early family relationships. Since Freud first presented his psychoanalytic formulations, family alli-

*Paper presented at the annual meeting of the American Association for the Advancement of Science, January 27, 1975, in New York, New York.

Irene Goldenberg, Ed.D., Assistant Professor of Medical Psychology, Director of Psychological Services (Children's Division), Neuropsychiatric Institute, University of California, Los Angeles.

Herbert Goldenberg, Ph.D., Professor of Psychology, California State University, Los Angeles.

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318 IRENEGOLDENBERG AND HERBERTGOLDENBERG

ances and conflicts (e.g., the Oedipus complex) have been commonly accepted as important factors in an individual's character formation and particularly in the development of neurotic behavior. However, until fairly recently, most psychotherapy, influenced by psychoanalysis, involved working with individuals alone to resolve their personal, intrapsychic conflicts. Except in the case of children receiving psychological help at a child guidance clinic, where it was expected (and sometimes made mandatory) that the child's mother (if not always the father) also come regularly for individual sessions, other family members were rarely involved in one member's psychotherapy. In this way, the notion was perpetuated, and rarely challenged, that individual psychopathology was the result of intrapsychic conflict alone, based on historical antecedents.

In the mid-1940's, the situation began to change. In addition to the rapidly expanding child-guidance movement, there was increased interest in marriage counseling, an acknowledgment that individual distress was as much a result of flawed interactions as intrapsychic pressure. In addition, the successful wartime reliance on group-therapy methods led many mental-health workers to reassess their former insistence both on the inviolable doctor/individual patient contract (confidentiality, etc.) and on the unidimen- sional intrapsychic explanations for disordered behavior. The work of Harry Stack Sullivan, 1 an American psychiatrist who devoted a large share of his professional career to developing better ways of understanding and treating schizophrenics, is noteworthy here. On the basis of his clinical experiences he came to conceive of all disordered behavior as a result of disturbed or distorted interpersonal relationships.

Theories of Family Pathology Several groups of clinical researchers, beginning in the 1950's and working inde-

pendently of one another at first, started to take a closer look at the social interaction patterns within families in order to investigate the possible link between specific fea- tures of family life and the etiology of disordered behavior. In particular, the focus of attention turned to the patterns of interaction and communication within a family in which one member had been labeled as schizophrenic, in hope of determining if certain distinctive patterns exist in such families and, further, what influences such patterns may have on the development of schizophrenia. 2

The conceptualization of schizophrenia as part of a family process stems in large measure directly from the work of Frieda Fromm-Reichmann, an early associate of Harry Stack Sullivan. Based upon her experiences in working with hospitalized schizophrenics, Fromm-Reicl~mann 3 proposed that there typically existed a "schizophreno- genic mother" - domineering, cold, rejecting, possessive, guilt-producing - who, together with a passive, detached, and ineffectual father, caused their (male) offspring to be confused and to feel helpless and inadequate when face to face with life's stresses. This hypothesis, most popular through the 1950's, gradually shifted in the next decade to one emphasizing the entire pathological family network, rather than the more sim- plistic notion that there are malevolent, villainous parents and innocent, put-upon children. Today it is popular among many clinicians 4 to perceive the family as a social system that operates through transactional patterns, with each member influencing the system and in turn being influenced by it in constantly recurring sequences of interaction. In a sense, all the family members are caught up in a reverberating circuit; any individual member's disorder is but one manifestation of a general family disorder.

FAMILY PSYCHOLOGICAL SERVICES 319

Concentrating on the family's communication pattern, especially the mother-child interaction, one group of investigators led by anthropologist Gregory Bateson s proposed the double-bind theory to account for the development of schizophrenic behavior in some children. A double-bind situation is one in which a person receives contradictory messages from the same individual, is called upon tO make some response, but is doomed to failure whatever response he makes. Bateson et al. give the following poignant example:

A young man who had fairly well recovered from an acute schizophrenic episode was visited in the hospital by his mother. He was glad to see her and impulsively put his arm around her shoulders, whereupon she stiffened. He withdrew his arm and she asked, "Don't you love me anymore?" He then blushed, and she said, "Dear, you must not be so easily embarrassed and afraid of your feelings." [Page 259]

The authors go on to report that the patient, distressed, promptly became violent and assaultive when he returned to his ward.

Double-bind situations are thought to occur with great regularity in some families,

frequently involving real but not always readily apparent contradictions between what is said aloud and what is simultaneously communicated by gesture or tone. For example, a father may verbally inquire with simulated interest and enthusiasm what the child did at school today, but at the same time reveal his disinterest through his nonverbal behavior by not looking up from the newspaper he is reading despite the child's a t tempt to respond to his question. Bateson and his colleagues suggest that repeated and prolonged exposure to such contradictory experiences typically results in the child learning to escape hurt and punishment by responding with equally incongruent messages; as self-protection, he learns to deal with all relationships in such a distorted manner, finally losing the ability to understand what is the true meaning of his or others ' communication messages. At this point he begins to manifest schizophrenic behavior. The interdisciplinary group at the Mental Research Institute in Palo Alto, led by Bateson, thus focused on schizophrenia as a prototype of failure in a family's communication system.

Another series of clinical investigations of family patterns has been carried out at Yale by Theodore Lidz and his colleagues. 6'7 They suggest that the parent 's (usually

the mother's) own arrested personality development leads to an inability to meet the child's nurturance needs, so that the latter is likely to grow up with profound insecurity, unable to achieve autonomy. In addition, an unstable marriage, with considerable conflict between husband and wife, and especially where one or both mates themselves are psychologically disturbed, is linked directly with providing poor role models for their children; the consequence, at least for some of the children, is the inability to learn adequate or appropriate age- and sex-related social roles, necessary in interacting with others outside the family. It can be seen from this brief description that to Lidz it is the psychodynamics of the parents, rather than the family as a social system, that is primarily responsible for the development of disordered behavior in their child. Such parents typically fail to transmit the basic adaptive techniques necessary to function effectively in the culture.

Lidz et al. 7 describe two patterns of chronic marital discord particularly character- istic of schizophrenic families (although each may exist in "normal" families to a lesser

320 IRENE GOLDENBERG AND HERBERT GOLDENBERG

extent). Marital schism refers to that disharmonious situation where each parent, pre- occupied with his or her own problems, fails to create a satisfactory role in the family compatible and reciprocal to the spouse. Each tends to undermine the worth of the other, especially to the children, for whose loyalty, affection, sympathy, and support they compete. Because they do not value or respect each other, each may voice fears that the child will grow up behaving like the other parent. Threats of separation or divorce are common; it is usual in such families for the father to become ostracized and a nonentity if he remains in the home. In the pattern ofmaritalshew, also observed in families with a schizophrenic offspring, the continuity of the marriage is not threatened, but mutually destructive patterns nevertheless exist. Typically, the serious psychological disturbance of one parent (e.g., chronic alcoholism) dominates such a home. The other parent, often dependent and weak, accepts the situation and goes so far as to imply to the children that the home situation is normal. Such a denial of what they are living through may lead to further denials and distortion of reality. Male schizophrenics are believed to come from "skewed" families where there is a dominant, disturbed mother and a passive, ineffectual father. The latter provides his son with a poor role model. On the other hand, female schizophrenics are believed more likely to come from "schis- matic" families where there is open marital discord and each parent particularly wants the daughter's support. However, the father's disparagement of the mother (or perhaps all women), plus his seductive efforts to gain the daughter's love and support, leads to a confusion in her identity as a woman, as well as to her later inability to successfully carry out her female role in society.

At the National Institute of Mental Health (NIMH) near Washington, D.C., studies of the family interactive process between the schizophrenic and his family have been in progress for two decades. Murray Bowen, 8 an early worker in the field of clinical research with families, found certain patterns that resemble Lidz' findings regarding marital schism. Bowen termed the striking emotional distance between parents in such a situation as "emotional divorce." He described such a relationship as vacillating between periods of overcloseness and overdistance; eventually the pattern becomes fixed at an emotional distance from one another to avoid anxiety, settling instead for "peace at any price." One area of joint activity - and commonly of conflict revolves around their opposing views regarding child-rearing, particularly of those children showing signs of psychological disturbance. It is as if they maintain contact and therefore a semblanceofemotional equilibrium between themselves by keeping the disturbed child helpless and needy. Thus, adolescence, a period where the child in particular strives for some measure of autonomy, becomes especially stormy and stressful and is typically the time when schizophrenic behavior manifests itself. Bowen proposes the intriguing notion that schizophrenia is a process that spans at least three generations before it becomes manifest in the behavior of a family member. What he is suggesting is that one or both parents of a schizophrenic are troubled, immature individuals who themselves have emerged from serious emotional conflict with their parents, only to engage their offspring in similar conflict situations.

Lyman Wynne 9 at N[MH also has concerned himself generally with the social organization of the family and particularly with the nature of the interpersonal relationships and identity formations in families with schizophrenic members. According


to Wynne, pseudomutuafity- giving the appearance of a mutual, open, and understanding relationship without really having one - in such families conceals an underlying distance between members and represents a shared maneuver designed to defend against pervasive feelings of meaninglessness and emptiness among all family members. A strong sense of personal identity, which requires testing out through honest and meaningful feedback information from others in ord.er to develop, cannot be formed under such circumstances; moreover, efforts to assert such individuality are likely to be per- ceived as a threat to the facade of mutuality. In Wynne's formulation, schizophrenic behavior may be a reaction to an identity crisis caused by the threat of separation from the familiar pseudomutuality of the family.

Early Models of Family-Therapy Practice

Most workers in the field of family therapy would probably agree with the judg- ment 1° that Nathan Ackerman and Virginia Satir - the former a psychoanalyst until his recent death, the latter a social worker - deserve credit as the East and West Coast charismatic leaders of the field. Ackerman began working with the family as a social unit, originally within a psychoanalytic framework, in the early 1950's. His pioneering and influential book, The Psychodynamics of Family Life, 11 pointed the way to prac- ticing therapists in viewing the family as a kind of "carrier" of elements predisposing family members to psychological disturbance or mental health. Ackerman suggested that the family member who develops psychiatric symptoms may often prove to be the emissary in disguise for the whole disturbed family in need of treatment. He or she may simply be the scapegoat behind whom the family hides its own dysfunction. Viewing the family as a social system with properties greater than the mere summation of its members' characteristics, Ackerman12 suggested that the behavior of any n'lember may be interpreted in four ways: (1) as a symptom of the family unit's psychopathology; (2) as a stabilizer of family functioning; (3) as a healer of family disorder; and (4) as the epitome of the growth potential of the .family group. Intervention or treatment, according to Ackerman, consequently should focus on the relationship between the individual emotional functioning of family members and the psychosocial functioning of the family unit.

Through a series of office interviews and home visits with the entire family, the family therapist, following Ackerman as an example, is able to obtain a firsthand diagnostic impression of the dynamic relationship among family members. Ackerman is said 1° to be a "conductor" type of family therapist, an active family-group leader who places himself in the center of the family's star-shaped verbal communication pattern. (Others, like Jay Haley ~3 are classified as "reactor" types, observing family interaction patterns while exerting a more subtle influence on the family communication system.) Ackerman mobilizes family interaction, looking for verbal and nonverbal cues to basic family patterns involving sex, aggression, and dependency. As a "conductor" type, direct and active, he forces openness and the surrender of ordinary defensive behavior.

Satir, 14 working with the Palo Alto group that earlier developed the double-bind theory of family communication, is herself interested in teaching lqhe family more honest and effective communication patterns. A widely known family therapist through her book, Conjoint Family Therapy, as well as her demonstrations around the United


States, Satir is also categorized as a "conductor" whose approach is direct, simple, and straightforward. She sees her role as that of a resource person, an experienced observer from outside the family who herself is a model of clear, open, and simple communication. Typically she attempts to use her expert status to teach family members how to correct discrepancies in their communications and therefore achieve deeper and more mutually satisfying relationships. Together, Ackerman and Satir can be considered to have provided the basic models of most family-therapy practice today.

Some Current Techniques of Family Therapy

There are at this point no established "schools" of family therapy. Some therapists (e.g., Ackerman) operate from a psychoanalytic vantage point, others (e.g., Satir) stress communication patterns, still others have attempted to apply behavioral or learning theories to modify or restructure a family's "interpersonal environment." A therapist's approach to a particular family will depend on several factors - his or her clinical orientation, skill, and training, as well as perception of how best to intervene therapeutically. Since techniques of family therapy are not yet highly formalized, therapists commonly experiment with various combinations and shift from one approach to another at different phases of therapy. Thus, many therapists see whole families first and then shift to the parents, the siblings, one individual, or any combination that seems appropriate for the problem involved. Or they might start with the individual and later bring in his family. Some therapists are beginning to see several families together (multiple family therapy). Others make home visits, sometimes seeing the identified patient, usually schizophrenic, along with his entire network of social, family, and kinship relations (network therapy).

Family Behavior Therapy

Behavior therapy or behavior modification represents a systematic effort to apply the principles of learning, especially conditioning, derived from the psychology labora- tory, to the clinical treatment of disordered behavior. Although for the most part developed as a technique for removing learned maladaptive behavior in individuals, is recent efforts have been made to apply the behavior-modification process to family therapy, a6 The behaviorally oriented therapist sees the family-therapy situation as an opportunity to induce significant behavioral changes in the family members by re- structuring their interpersonal environments. 17 Instead of being caught up in, and re- warding, maladaptive behavior with attention responses that socially reinforce the undesirable behavior (perhaps nagging, sympathy, babying, anger, or irritation), family members learn to recognize, approve, and thereby positively reinforce only each other's desired behavior. The deviant member continues with his manipulative behavior or set of symptoms only so long as the family expresses interest and concern, even if inter- mittently. The behaviorally oriented family therapist makes a behavioral analysis of the problem in the family, determining what behavior patterns in others each member would like to see increased or decreased. At the same time, he focuses on what environmental or interpersonal contingencies currently support the problem behavior. Once identified, the family is guided to change the contingencies of their social-reinforcement


patterns from maladaptive to adaptive target behavior. Sometimes modeling and imita- tion facilitates change, as the therapist or a family member exhibits desired, adaptive behavior. From this point of view, family therapy is viewed as a learning experience, with the therapist as an educator, model, "shaper," and himself a social reinforcer. Within the family system, it is assumed that the most important controlling stimuli for any single member's behavior are the behaviors of other members. Producing behavior changes in one member requires altering those environmental conditions, including the behavior of other members, that maintain the undesirable behavior. For example, parents can be trained to accurately observe and keep records of the antecedents and consequences of deviant behavior in a child in order to plan with the therapist and carry out a therapeutic program based upon behavior-modification principles. Families who receive such training are able to continue to apply these principles after family therapy is terminated.

Multiple-Impact Therapy

In an effort to provide therapeutic intervention for a family with a disturbed adolescent in crisis, MacGregor, Ritchie, Serrano, and Schuster 18 at the University of Texas in Galveston have developed a unique, intensive, crisis-focused approach to family therapy. An entire family comes for two days of continuing interaction with a team of mental-health professionals. Beginning with a brief, initial diagnostic-team/family conference, various combinations of team members and family members split up into separate conferences; therapists overlap in working with different individuals or combinations; multiple therapists work with the same individuals or pair of family members; team-family conferences are held periodically; and occasionally two family members (perhaps father and son) may be left alone to work out certain problems themselves. Before leaving, follow-ups are arranged, varying from six weekly visits by the parents to a half-day session three months later. Multiple-impact therapy aims less to provide family members with insight than to change the family from a relatively closed system to an open system conducive to growth. Open communication, mutual acceptance, clear role differentiation between members, flexibility to attempt new ways of relat- i n g - especially to and by the disturbed adolescent are all encouraged so family members can give up playing their repetitive roles in a reverberating system and begin to explore new ways of growth. Multiple-impact therapy is based upon a psychoanalytic understanding of personality development combined with a here-and-now effort at therapeutic intervention.

Home Visits and Family Therapy

One innovative approach to delivering psychological services to a family involves home visits by therapists. Although still more the exception than the rule~ reports are beginning to appear in the literature on both the diagnostic and therapeutic value of such an approach. Behrens 19 notes that with patients from lower socioeconomic classes there frequently is resistance to coming to a clinic for.psychological problems; those who do, moreover, frequently find meaningful communication with the professional staff difficult if not sometimes impossible. Under such circumstances, brief and occa-


sional home visits have proven feasible in gaining a better understanding of family dynamics, improving patient(s)-therapist relationships and preventing hospitalization by visiting patients at a time of crisis. In addition, occasional or regular home visits by one or more therapists have the following advantages: (1) The total functioning of the family is more evident, with less opportunity to disguise or deny behavior or be on best behavior; (2) each family member is more apt to play his everyday role, forcing the therapist to undergo an unnatural role shift, rather than vice versa; (3) there is less chance of absenteeism by a family member, a common phenomenon in the office practice of family therapy; (4) there is more likely to be a tacit recognition that the entire family has problems, rather than that a single family member requires psychotherapy in or out of a mental hospital; (5) there is apt to be less anxiety in familiar surround- ings, encouraging more open communication and less artificial role playing to impress the therapist; and (6) the therapist is less likely to be treated with the stereotyped def- erence inherent in the usual patient-doctor relationship. Social workers and public- health nurses have long practiced family therapy in the home, now other mental health professionals are following their examples, either on a regular basis or on specifically chosen occasions. Ackerman 11 has found that the home visit is especially useful for diagnosis. He has found the best time to visit is at the evening mealtime when the family normally comes together. Arriving before the father returns from work, the therapist is in a better position to evaluate changes in the family organization, attitudes and feelings with the arrival of the father. Ackerman is particularly interested in gaug- ing the family interaction patterns, the emotional climate of the home, specific conflicts between family members, and patterns of restitution after conflict in the family. While Ackerman's efforts in the home are directed primarily at family diagnosis, Friedman et al. 2° are interested in the possibility of treating schizophrenic individuals in their home settings as an integral part of the group treatment of the entire family. Rather than hospitalize a young schizophrenic, particularly when his family is living together, Friedman has conducted regular family therapy in the home. A number of detailed case studies show this method as modifying the schizophrenic's disturbance, as well as creating more effective family group functioning and a more satisfactory social life for the entire family as a unit in the community.

Family Crisis Therapy

Crisis intervention is a relatively new psychotherapeutic approach which is brief, promptly available, action oriented, and directed at current here-and-now psychological problems. Crises occur not only to individuals but also to families, where divorce, death, an alcoholic parent, a runaway child, a heavy drug user, and so on may cause multiple problems for all the family members. The Family Treatment Unit at the Colorado Psy- chiatric Hospital offers outpatient crisis therapy to families where one member would ordinarily be hospitalized. Part of the rationale for this approach is the belief that re- moval of the disturbed individual from his family to a hospital may do little else than scapegoat that person and avoid the very family problems that may have precipitated the crisis that led to his disturbance. Instead, families in acute crisis situations remain


together and receive intensive family therapy, averaging three weeks in duration, including office and home visits, rather than individual psychotherapy or hospitalization for any member. 21 If necessary, referral for long-term therapy may be made for an individual or the entire family. In a carefully designed experiment of families with schizophrenics, Langsley et al. assigned alternate patients to the Family Treatment Unit, while the others were hospitalized and served as controls for those receiving family crisis therapy. In all, 300 patients, 150 in each group, were involved. The average length of hospitalization for the control group was twenty-six days; t reatment for control-group families included individual and group psychotherapy, drugs and parti- cipation in the hospital therapeutic community program for the hospitalized patient, with the rest of the family seen separately with a focus on the patient's problems. A six months follow-up revealed that family crisis therapy patients were less likely to be hospitalized within a half year following treatment than control group patients were to be rehospitalized, if hospitalization does become necessary, it is significantly shorter for the experimental group. Eighteen months follow-up evaluation 22 showed similar significant benefits to those receiving family crisis therapy, although differences in hospitalization rates between the two groups tend to decrease with time if further crisis treatment is unavailable.

Network Therapy

Some therapists have begun to extend the concept of family treatment of schizophrenics in the home by including all members of the identified patient's "social network." By this they mean that home treatment might be aimed not only at the schizophrenic and his family, but also might involve members of his extended family, friends, neighbors, and all others who play a significant role in his life. Network therapy is based on the assumption that there is significant pathology in the schizophrenic's communication patterns with all members of his social network, not just with his nuclear family. This approach works at tightening the network of relationships, making the entire group as intimately involved as possible in each other's lives. Speck and Rueveni, 23 developers of this method, see such networks as analogous to clans or tribal units; their major benefit is in offering support, reassurance, and solidarity to its members. In practice, members of the network (as many as forty in number) gather in the home of the schizophrenic patient and his family, much as a tribe in a crisis situation might assemble. Thus, family, relatives, and friends are mobilized into a potent social force, particularly appealing in an age of increasing depersonalization and aliena- tion. Such intervention aims to create a climate of trust and openness among all members as a prelude to constructive emotional encounters between them. Ultimately it is hoped that bonds between people will be strengthened, overt communication increased, and double-bind messages removed. Usually a team of professionals is present at six weekly four-hour sessions; some networks continue meeting on their own for varying periods of time thereafter. Not only are friends, family, and neighbors thus alerted to the problems of the schizophrenic and his family, but they also have an opportunity to therapeutically intervene on his or her behalf.


Multiple-Family Group Therapy

Several clinicians 24'2s have recently begun to treat several families simultaneously. Usually used in a hospital situation where there are rarely enough therapists for individual patients or individual families, multiple-family therapy makes it possible to treat up to six hospitalized patients and their families in a group. In addition to increased efficiency, such an approach has proven useful in helping the patient adjust from a structured hospital milieu into an unstructured home situation. Berman has re- ported promising preliminary data, based on a year's operation of such a program in a Veterans' Administration hospital. The readmission rate of past patients in such a program has been zero, compared to 30 to 40 percent of comparable patients ordinarily re- admitted within a year of hospital discharge. Apparently the increased awareness and resolution of interpersonal difficulties in the family have been the most beneficial factors. In general, the benefits of such an approach accrue from the combined benefits of family and group therapy. Group identification and support, easy recognition of, and quick involvement with, each other's problems, seeing one family's communication problems portrayed by another family, and Iearning how other families sotve their relationship problems appear to be particularly valuable. In addition, the therapist may use less disturbed families as co-therapists in an effort to reach more disturbed famities. Learning new patterns for resolving conftict may come from observing another family handle an analogous conflict situation more successfully. New experiences with parents other than one's own may be enlightening and less threatening. 26 In the experience of the senior author in training advanced graduate students in family therapy, it has been found useful to hold a multiple-family marathon session in which supervisors, student therapists, and their patient families together meet as a therapy group over a full-day's period. All of the advantages described above for multiple-family therapy are contained in the use of the multiple-family marathon as a teaching device. In addition, student therapists gain experience and add to their proficiency as family therapists by exposure to a variety of family networks and interaction patterns facilitated by the marathon group, whose time-extended, uninterrupted session intensifies and accelerates ordinary therapeutic effects.

Conclusions

A family approach to psychological services has become, within the last twenty years, an increasingly popular therapeutic technique. In particular, there are at least two situations in which the clinician is likely to deal therapeutically with the entire family rather than with one of its members: (1) when individual therapy has failed or been very slow, with frequent relapses due to the family's resistance to any attempted change in the individual; and (2) when individual improvement due to individual therapy has led to considerable distress and the appearance of symptoms in one or more of the other family members. In addition, family therapy would seem to be pre- ferred for: (1) marital problems; (2) generation conflicts between parents and children, especially adolescents; and (3) various family crises. Therapy for schizophrenics that includes their families has become more common and has been somewhat more successful than individual psychotherapy.


Family therapy is not simply treating individuals in a family context; the disordered family process must be changed. However, since most family therapists were trained as individual therapists, many continue to perceive individual psychopathology as their central concern while acknowledging the context of family life in which such psychopathology developed. Others focus on the disequilibrium in a family, considering individual intrapsychic conflicts to be secondary to improving the family's functioning as a more effective unit. The individual-oriented therapist is likely to work with families but retain his focus on the individual. In effect, he attempts to adapt individual therapy to the family situation. The family-oriented therapist is interested in the family as a system. He believes his approach is a more realistic way to understand family psychopathology and a more efficient way to treat it in individual family members. To him, the traditional psychotherapeutic focus on the separateness and autonomy of the individual has made treatment difficult and prevention all but impossible. Family- oriented therapy can strengthen the family by helping it achieve a stronger sense of

,unity and an ability to communicate and to work together constructively in realistic, mutually accepting, satisfying ways.

The significance of family therapy as a system for delivering psychological services extends beyond the addition of simply another therapeutic tool. The approach has shattered reliance on conventional but oversimplified dichotomies such as the "sick" and the "well" within a family, the "good" and the "bad," perhaps even the "healer" and those to be "healed." In family therapy, people are seen in context and the multi- plicity of motives and interactive bases for their behavior are emphasized. Closer to the real world in which his patient functions, the family therapist's margin for error of interpretation is narrowed. The identified patient no longer steps into the world of the therapist; instead, it is the latter who enters the former's world. The impact of this shift on the family therapist is bound to be real and meaningful. His chance to function as an effective agent of change is correspondingly more probable, more immediate, more real, and with the likelihood of longer-lasting results.

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A family approach to psychological services