Family Therapy-

7/28/2019 Family Therapy-

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Speaker: Dr. Pavan kumarChairperson: Ms. Malarmathi


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Introduction to Family Therapy Normal family functioning Schools of Family Therapy Systemic F.T. Strategic F.T. Structural F.T. Extended F.T. Cognitive Behavior F.T. Psychodynamic F.T.

Experiential F.T. Psychoeducation

Indications and contraindications Efficacy of Family therapy in various disorders Recent trends


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Vastly expanded and gained wide acceptance in last 4decades.

42% of people who sought professional help forpsychological problems viewed their problems asrelated to a marital problem

and another 17% viewed as pertaining to familyrelationships. Gurin, Veroff and Feld (1960)


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Family therapywhen more than one member ofa family are seen together in psychotherapy.

Conjoint FT-when seen at one time.

Concurrent FT- when seen in different sessions

Excludes therapies that focus on single

symptomatic client in family and social system (egBowen therapy)


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Any psychotherapy endeavor that explicitly focuses on

altering the interactions between

or among family members and seeks to improve thefunctioning of the family as a unit

or its subsystems, and/or the functioning of individual

members of the family.Gurman et al (1986)


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Family therapy is a mosaic of techniques, all of whichhave the shared goal of direct alteration of maladaptivefamily processes.

Controversy regarding couple therapy to include inFP(family subsystem) or not (as different skills

applied).


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Classified along 2 axes

1st consisting of who is seen in treatment( eg.Individual, couple, nuclear/extended family)

2nd the theoretical perspective of which the therapy

centers (eg. Structural, strategic, object relations, or atype of integration).


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Child guidance clinics of early 1900s - Adler'sinvolvement of parents in the therapy for theirchildren, represented a significant departure from

the dyadic psychoanalytic model prevalent at thetime.

Nathan Ackermanfounder of family therapy

Earliest CT and FT framed as direct extension ofexistent models of individual therapy.


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FT leapt to prominence through the work in1950s&60s by Nathan Ackerman, John Bell, IvanBoszormenyi-Nagy, Murray Bowen, James Framo, JayHaley, Doanld Jackson, Salvador Minuchin, VirginiaSatir, Carl Whitaker, and Lymen Wynne

Prominent view- causality is best conceived of as acircular process in which behavior is seen asinterdependent and subject to mutual influence.


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Family was viewed as the principal locus of the

problem, central in its development, and the most

appropriate context for treatment.

Theories(schools) developed in backgrounds ofpsychoanalysis, behavioral, social

systems(structure overcoming family homeostasisor integrational process), anthropology,communication, hypnotherapy


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Shift from Schizophrenia to other disorders.

In 1970s & 80s FT passed through the phase emphasizing

differences across the many distinct schools that emerged.

No objective observers- therapists become part of thesystem being influenced by it as well as influencing it.

An integrative viewpoint that includes not only familymethods of intervention but also at the level of individualand larger system.


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Provides for the needs-material, emotional,

spiritual of family members.

Basic processes involves integration, maintenanceand growth of family unit.

Normality range- asymptomatic functioning-

statistically average- optimal functioning.

Normality defined by social, temporal context &needs adaptation to internal and external demands

over the course of family life cycle.


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Barnhill (1979): 4 basic themes-(8 dimensions)

Identity Processes

Individuation Vs Enmeshment.

Mutuality Vs Isolation.

Change

Flexibility Vs Rigidity.

Stability Vs disorganization.

Information Processing

Clear Vs Unclear or distorted perception.

Clear Vs unclear roles or role conflict.

Role Structuring

Role reciprocity Vs unclear or conflictual roles.

Clear Vs diffuse or breached intergenerational boundaries.


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Fleck(1980)- 5 parameters of family functioning-

Leadership: parents personality, roles, disciplinary styleetc

Family Boundaries: ego, generation and family-community boundaries.

Affectivity: interpersonal intimacy, tolerance to each

others feelings, unit emotionality etc. Communication: consistency, expressiveness,

responsiveness to each other etc

Task/goal Performance: nurturance, behavior. Control &

guidance, crises management, adaptation etc.


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Task accomplishment problems.

Communication problems.

Role problems.

Behavior control problems.

Poorly functioning sub-systems & boundary problems.

Supra-system problems.


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Toddler

School

going child

Adolescent

Launching

the child

Retirement

Empty home

Honeymoon


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Evidence of family dysfunction

Evidence that family dysfunction related to clinical

presentation.

Relationship & interactional problems

Failure of other treatments

Favorable Evidence base


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Practical / geographical limitations.

Poor therapist match.

Severe medical illness.

Incapacitating psychiatric disorders.

Escalating physical harm.

Working with divorced parents.


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Most central being the influence of the socialsystem in influencing individual behavior.

GENERAL SYSTEMS THEORY (Von

Bertalanaffy, 1969)- understanding all systems,animate and inanimate with central tenet that

whole is more than the sum of its parts.

To understand any part (eg. An individual), onemust grasp its relation to the whole of which it isa part( family).


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Equifinality- suggests that there are many ways ofreaching particular configurations within thesystem and that the particular pathway by which aconfiguration has been reached doesnt matter.

Applied to family systems, equifinality focusesconcern on the state the family is presently in and

not how the family reached that state.


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Behavior is understood as a function of theCONTEXT in which it is conceived.

Classic ex- the meaning of seeing a man quacking atducks is significantly altered by the knowledge thatthis man is Konard Lorenz engaged in experimentsabout imprinting.


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Severe mental illness was seen as product of behavior

that made sense in a particular context(eg withinfamily process), although it appeared to make little

sense outside of that context.

identified patients- family members displayingpsychopathology or other problematic behavior

appropriate in family context, so family therapy ismost appropriate method of bringing change. (X)dismissal of biological basis of severe mental disorder.


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Circular paths of causality- Rather than focusing on

linear pathways of actions followed by reaction,attention centers on recursive patterns of mutualinteraction and influence.

The system, not a single person, is responsible for thebehavior that is maintained through such circularpathways.

(X) family violenceinstance where individualresponsibility and linear arcs of causality otherwisebatterer and victim are coequal in responsibility for

violence behavior.


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CYBERNETICS- science of communication andcontrol in man and machine, developed by Weiner etal.

Systems are viewed as self- correcting to maintain asteady state(homeostasis), influenced by feedbackeither +ve orve.

Every FT was profoundly influenced by the idea thathuman systems were homeostatic, moving toward thereduction of change. As a result most 1st generationFT were based on the notion that powerful

interventions needed to reorganize the family.


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Systemic thinking has given more weight toMORPHOGENESIS, the natural force moving thesystem toward change.

Initiating the process of small changes is likely to kickoff a positive chain reaction, while in homeostaticmodels most powerful interventions needed toproduce change.

Similar process- AUTOPOESIS, (Maturana andVerela,1980)- internal structure of the living systemdetermines its behavior, therapist can only perturb thesystem to make changes that the client system itselfproduces.


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Couple and Family therapies can be divided into

following categories on the basis of emphasis. Structural Strategic Cognitive-behavioral Psychoeducational Intergenerational Psychodynamic

Experiential Narrative and Integrative schools of FT


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Remains most influential school with in familytherapy aiming ultimately at restructuring the

family system.

Developed by Salvador Minuchin largely drawnpurely from systemic concepts.

Emphasizes the power of the social system asmanifested through family structure.


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Given the homeostatic vision of systems as base oftherapy, therapists create powerful in-sessionexperiences to work to alter the familys

organization.

Minuchin, by family structure means the regulatingcodes as manifested in the operational patterns

through which people relate to one another inorder to carry out functions


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Three primary dimensions of structure are boundary,

alliance, and power.

Boundaries are rules defining who participates andhow, who is in and who is out of an operation,regulating contact.

Strength of boundaries vary, ranging from rigid(families act like they have little to do with each other),resulting in disengagement, to very permeable(violating the boundaries and intruding into functionsof others), resulting in enmeshment.


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Structural FT aims to move families away from theextremes of enmeshment and disengagement.

Alliances are the joining or opposition of onemember of a system to another in carrying out anoperation.

Alignments become dysfunctional when theybecome fixed and unchanging (stable coalitions) orwhen they primarily cross-generation.


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Triangulation describes the process of two peopledemanding that a third join with them against the

other.

Structural FT aims to create alliances that arefunctional(eg parents with one another), while at the

same time not becoming rigid.


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Power describes the relative influence of each familymember on the outcome of an activity,

may be with older generation, one individual orcoalition.

Power is seen best held in the hands of an executive(eg a parental coalition), but in such a fashion to leaveeveryone with some degree of power.


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Therapist promotes family members habitualpatterns of relating (called enactment) with thefamily.

Emphasis in joining with the family throughtracking (adopting the symbols of family life),

accommodation (relating to the family in

congruence with the familys patterns),

and mimesis (joining with the family by becomingthe like family in manner or content).


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Symptomatic change in identified patients is assigned

a much less important role than change in the structureof the system

Criticism- gender based of some assumptions instructural FT, as approach on equifinality so limitedconcern with history or internal process of individuals.

Minuchin (1996) has recently moved to a more genderaware version and acknowledged importance of history


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Most purely systemic of the family therapies.

From the strategic viewpoint, change is a discontinuousprocess.

The goal is to intervene briefly, find a new way offunctioning that works better, and promptly end thetreatment.

Paradoxical interventions - directives are offered which

if acted on, would move the family against the direction inwhich it is directed.

Reframing- active efforts by the therapist to create a newand different understanding of old events that has a more

benign meaning. MC intervention in CT and FT.


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Use of team approaches, utilizing observers

behind one way mirrors as part of interventionprocess,

typically offering commentary or directives to thetherapist and family.

Change, not learning about the change process, iscentre of attention- altering feedback cycles, butnot providing insight about such cycles.


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TYPES:

MRI (Mental Research Institute) / Palo Alto model

Haleys problem solving therapy

Milan systemic therapy

Solution-focused therapy.


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First systems-based strategic model within FT

Developed by Jackson, Watzlawick, and Weakland.

Derived from a mix of systems theory, cybernetics andthe study of communication process.

Always remain brief & focused, with therapistattachment isnt long term and terminated as soon asproblem resolution is initiated.


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Problems are viewed as a natural part of family lifethat families regularly deal with on their own.

Need for intervention is seen as stemming notfrom the problem itself, but how family memberstreat the problem.

When families efforts to solve problems(more of

the same), changes in behavior, termed first-order change which unlikely resolve the problemand make even worse.


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Therapy focuses on second- order change, analteration of rules that lie beneath the behaviors

maintaining the problems.

Reframing and paradoxical interventionsmostpowerful tools for initiating 2nd order change.

Exemplar of strategic FT, rarely practiced in pureform and lacks empirical support.


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Haleys and Mandanesstrategic use of paradoxicaltechniques with goals that typify structural FT.

Emphasizes grasping and working with the function

(struggle for power and control) that behaviors servewithin the system.

Derived from the hypnotic work of Milton Erickson,

aimed at increasing suggestibility and openness tochange.

ex pretend technique, a paradox technique thatsuggests possibility of overt control over patterns

thought to be out of conscious control.


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specific observation by therapist on triangles(whosupports whom in interaction)

and hierarchy(who has what power), directives to familyin new and different behaviors.

Highly controversial in view that identified patientscarry symptoms due to family dysfunction and a denialof existence of mental illness

ie not due to biology or individual psychology.


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Developed in Milan, Italy by Selvini- Palazzoli,

Boscolo, Cecchin, Prata and others

Team behind a oneway mirror, forms a hypothesis

over the family, to be modified over the course oftreatment.

Intervention throughpositive connotation or

prescription of ritual.

Positive connotation- reframing behavior in positivelight, suggesting how behavior serves the goals of the

system.


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Rituals prescribed to exaggerate or move against rigidpatterns in the family.

Most rituals have ironic quality and engenderconfusion.

Ex: odd and even days- control given to each parenton alternating days.


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Boscolo and Cecchin variant- circular questions-questions used to learnt about differences in the

family that might provide clues to recursive familypatterns.

Curiosity is the essential ingredient in circular

questioning.


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The aim is not to move the family toward a specificgoal, but to initiate thought and conversation inorder to create greater understanding of how the

present situation and family behavior,

what the systemic patterns are that keep the familyfrom resolving their difficulties and what are mostproductive pathways toward change.


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Selvini- Palazzoli variant- disturbed patients were

inevitably caught up in dirty game, a powerstruggle between parents in which patientssymptoms help support one parent.

the invariant prescription- the therapistsuggests to parents that they tell family membersthat they have a secret and go out mysteriously

without warning other family members, and theythen observe the familys reaction.


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Aims to help strengthen the alliance between theparents and enable understanding of dysfunctionalpatterns in the family.

Milans approach though highly influential, small

number practice and little empirical testing available.


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DeShazer, Berg, OHanlon, and Weiner-Davis.

Assume that clients want to change and reject the

notion of deeply ingrained pathology

These approaches seek to introduce ways ofthinking about and facing difficulties that aredifferent and can kindle the familys own process

of resolving their difficulties.


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Employ miracle question- how would be, if allyour problems solved suddenly in a night when yourare asleep.

One favorite technique is to look for exceptions,times when problems have not been present or

overcome.

To nurture and help clients notice small changes fromwhich they can build larger ones


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All these techniques help clients begin to think in

terms of solutions and ability to resolvedifficulties rather in terms of problems and onesdifficulty in resolving them

The positive focus and optimistic frame of thesemodels has proven most welcome to families andtherapists alike.

Criticism- repetitive use of same few interventions(miracle question), least studied.


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Behavior principles in the treatment of family

systems.

Utilized in child behavior problems (esp CD and

child delinquency) and couple difficulties(maritaldissatisfaction).

Thoughts and behavior are central to all aspects

of functioning, the most efficacious pathways tochange directly address dysfunctional thoughtsand behavior patterns.


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Classical and operant conditioning, with latter assumedgreat importance.

Reinforcements central to operant conditioning, sociallearning theory(directly/modeling) shape behavior.

Social exchange theoryindividuals strive to maximizetheir outcomes, to increase the rewards they receiveand decrease the costs. (Thibaut and Kelly,1959)


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Behavior from one person is viewed as likely to be

met with reciprocity to behavior from another,

so social exchanges can become mutuallysupportive or coercive(punishing).

Couple dissatisfaction- product of low level of

positive reinforcement and high level of coerciveexchange within relationship


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skill training aims at providing knowledge about thisand to engage in appropriate behavior.

Cognitive theories of CBTemphasize thedevelopment and maintenance of dysfunctional orirrational thought processes,

and direct efforts to alter these cognitions throughlearning in therapy.


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Reciprocal influence(Patterson & Chamberlein) of

child and parent in CD, therapists has to remainsensitive in too frequent teaching behaviors thatpromote noncompliance.

Behavioral couples treatmentsempirical support, at least in short term effectiveness.


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Not only behavior , but involving feeling states, lead toformulation of noncontingent loving behavior calledcaring days or love days in CT.

Sex therapy in CTsensate focus by Masters andJohnsonanxiety is antithetical to sexual response andthrough classical conditioning, relaxation can replaceanxiety


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Parent training or CT in CBT involves assessment

of thought and behavior patterns connected totarget behavior, functional analysis of problematicbehavior,

formulation of plan specifying problem solvingskills training (in CT),

contingencies home token economies, pointsystems- preference for positive reward overpunishment in shaping behavior.


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Functional FT( Alexander and Parsons) for adolescentdelinquent behaviorexamine function and to enableengagement and cooperation in treatment.

Validated psychotherapies particularly approaches tochild and adolescent problems.


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Based on the notion that- Syndromes that seriouslyimpair functioning have a biopsychosocial basis.

Establish a collaborative partnership with families

who suffer from mental disorders, providing themwith the kind of information and skills, mostneeded for coping.

Eclectic mix of individual and family therapy thathave relevance to particular syndrome as well aspsychopharmacological interventions.


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Psycho educational FT developed in context ofschizophrenia and extended to other disordersmost notably manic depressive disorder .

Western psychiatric institute in Pittsburg andUCLA, developed psycho educational methodsfeaturing medication

for the person with schizophrenia along witheducation, survival skills workshops to familiesregarding expressed emotions


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With both these methods, expressed emotion has

been decreased, compliance increased, andrecidivism and symptoms decreased in index patient.

This work extended to families dealing with manicdepression ( Milkowitz and Goldstein).


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The strong evidence for the efficacy, lack of evidencethat FT works in these samples without the use ofmedication suggests psycho educational form of FT is

clearly superior to earlier variety.


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Bowen family systems therapy incorporates systemstherapy along with a unique language for consideringthe relationship of individual with family.

Concept of differentiation of self (thoughts andfeelings) from family process-

less susceptible to the pathology distinguished from

cut off (establishment of rigid boundaries thatminimize contact with family viewed as innatelyproblematic)


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In Bowens theory ,individual development islargely shaped by the family system.

Undifferentiated ego mass of beliefs and feelingsare transmitted through family projection processacross generations

In Bowen family systems therapy, each member of

the family involved to increase their ability tomanage their own anxiety and much of the workfocuses on the relationships clients have with theirfamilies.


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Family of origin is typically not seen directly in

treatment , but examined through forays outsidesessions

In which the client learns about family processes,experiences them and find new ways to cope withthem.

Coaching- therapist helps to examine thoughtsand feelings that emerge.


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Exploration- involves direct contacts with livingrelatives and efforts to learn about and experiencefeelings in relation to deceased family.

Much of Bowen family systems therapy is conductedwith only a single client in the office, though the workis principally centered on their family relationships.

It represents a bridge between individual and familytherapy.


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Basic notion- active dynamic internal process within

individuals.

Psychodynamic approaches share the belief that

unconscious mental process are extremely importantand that early experience has a crucial influence onlater behavior and experience.

Psychodynamic FT retained its individual therapycounterpart an emphasis on processes that occurwithin individuals


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Creating an appropriate frame, understandingtransferences in much relation to other familymembers, particularly spouses,

as in relation to the therapist, counter transference,projective identification

(therapist induced to feel or behave as the client has inpast or as others have behaved and felt toward theclient).


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Psychoanalytic therapies though not used in pure form,have been used in a variety of integrative approaches.

variantinsight oriented CThad promising future.


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Whitaker, Satir and Greenberg and Johnson

Felt experience- restoring liveliness and connection inthe therapy

The primary instrument is the therapist, who uses selfas an instrument toward change.

Whitaker utilized a wide array of techniques, rangingfrom direct commentary to physically wrestling withclients, all aimed to fight emotional deadness.


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Satir employed exercises from the human potentialmovement(belief that through the development of"human potential", humans can experience an

exceptional quality of life filled with happiness,creativity, and fulfillment)

Greenberg and Johnson utilize methods of emotional

focused interaction between couples derived fromGestalt therapy


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Michael White, Anderson and Goolishian, Combsand Freedman, Hare-Mustin

Social constructivismknowing is sociallyconstructed through language and discourse, anddepends on the context of the observer.

Difficulties are envisioned as the product ofstories that have been socially created and can bereconstructed.


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Problem-oriented descriptions are replaced by storiesof accomplishment.

Rather than merely opening discourse, theseapproaches also accent the feeling of repressed voices.

Much of the work is done with individuals, with only

passing references to the family system.


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Merge the raw material of the various approaches.This merger occurs at three distinct levels: theory,strategy, and intervention.

Therapists can build a personal method.

Moultrops and Lebows work suggests guidelinesfor each therapists model development,

offer examples of conceptions focused on thetherapist as an agent of integration


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Jacobsons couple therapy, Liddle, Dakof, andDiamonds treatment for adolescent drug abusers and

their families, Pinsof s problem centered therapy or

Gurmans integrative marital therapy.

Feminists(Goldner, Hare-Mustin, Aponte..) integratedtherapies giving importance to race, class and gender.

Research promising and proven highly effective.


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Initial contactEstablishing rapportDefining desired outcome

Review history, determine present developmentalstage & genogramAssess current functioningDevelop diagnostic formulationOffering feedback

Arranging further clarifications & referralsTreatment proposals


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Wile - Famil Thera - Conce ts, Process and Practice - 2nd Edn


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Behavioral approaches largely have extensiveresearch support, particularly in treatingchildhood and adolescent CD, maritaldissatisfaction, and adolescent acting out.

Structural approaches also have considerablesupport, particularly in child and adolescentCD.

A experiential approach to CT, emotionallyfocused therapy, insight-oriented therapy havegarnered research support.


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Psycho educational treatments of schizophrenia,

CBT of depression,

Multi-systemic treatment and functional family therapyfor adolescent delinquent behavior, and

Multi-dimensional family therapy for adolescent drugabuse have considerable research evidence


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Very little research support for a variety of widely practicedCT and FT includingBowen, narrative, humanistic,strategic, and solution focused therapies

CT and FT have been demonstrated considerable value intreating

depression, anxiety disorder, panic disorder,

schizophrenia, alcoholism, and marital adjustments in adults and CD, autism and drug abuse in children and adolescents.


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A shift has occurred in which interpersonalprocesses, feedback loops, and systems role in

problem generation

And resolution are still emphasized, but attentionbroadens to include individual functioning, thelarger social system and other levels of anlaysis.

Boundaries among individual, CT and FT andbetween schools of FT are blurring withdevelopment of more integrative therapies.


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Biology is clearly emerging in literature as imp variableof FT, the field of family systems medicine havecome to occupy much attention.

Very strong emphasis on intervention strategy

Tendency to develop specific variants of treatment torespond to the specific issues in particular kinds of

cases has emerging.

Much attention on meaning and methods forintervening in family violence has been gainingprominance.


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Gender and culture have emerged as vitalconsiderations in shaping practice.

Impact and relationship of systems larger than thefamily such as schools, legal system, poverty and peergroups,

On family dynamics Multisystemic treatmentstargeting multiple systems are beginning to emerge.


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An increasing emphasis on a life cycle perspective,whether the family is in developmental process andshape interventions accordingly.

Much more emphasis on health, normality andresilience as opposed to homeostasis, resistance andpathology.


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Culturally inappropriate Minimal father involvement Poorly defined role for siblings Counter transference. Inaccurate formulation Inattention to influential relatives


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Reluctance of family therapists to accept currentdiagnostic systems.

Power of biological wave.

Managed care limitations. Impending fragmentation of care.Absence of valid nosology/ classification of relationship

disorders.

Absence of objective outcome assessment.


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Systems formulations of family process and family systems

orientations to psychotherapy have become prominence since

1960s.

Approaches to CT and FT are increasingly integrative, integrating

a range of concepts and intervention strategies and including afocus on the individuals within the family as well as on the broader

social system in which the family resides.

Research supports the tenets of systems theory as an explanatory

set of concepts for family processes.


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Documents

Family Therapy-