FAMILY THERAPY

Generally, when a member of a family develops a problem, everyone in the family is affected.

Increasingly, families are going into therapy as units in an attempt to fathom the nature of their

difficulties and the means by which to deal with them. Family therapy is a burgeoning field, as

indicated by the numerous handbooks and overviews of the field that appear every year. Further

evidence of this interest is the special sections on the treatment of families that appear frequently

in clinical journals such as the Journal of Consulting and Clinical Psychology.

However, it is important to note that family therapy differs somewhat from simply involving

family members in treatment. Indeed, it is quite common to involve parents in the treatment of

youth, or sporadically to involve spouses, siblings, or additional support members in the

treatment of patients more generally.

In fact, most therapeutic approaches with children involve substantial interaction with parents to

help change the context in which children are raised. Some therapists may even refer to these

instances as “family therapy sessions.” Yet, true “family therapy” often is characterized by a

unique approach to treatment involving the conceptualization of psychological symptoms as

arising from the family system.

The Development of Family Therapy

Fruzzetti and Jacobson (1991) trace the origins of family therapy to the 19th-century social work

movement. However, family therapy did not immediately gain prominence. It was not until the

mid-20th century that family therapy became a popular form of treatment. Some of the delay had

to do with the long-standing dominance of psychoanalysis.

The perspectives of behaviorism and humanism paved the way for an alternative treatment like

family therapy to become a viable option for clinicians. The problems of individuals were
conceptualized in systemic terms, as a manifestation of some type of family dysfunction. This

new perspective on clinical problems was most evident in some of the conceptualizations of

severe mental disorders such as schizophrenia. In trying to understand schizophrenia, a Palo Alto

research group (Bateson, Jackson, Haley, Satir, and others) approached the problem from a

communication point of view. To influence a family member, one must deal with the entire

family system (Jackson & Weakland, 1961). Related to the idea of the family as a unit is the

concept of the double-bind (Bateson, Jackson, Haley, & Weakland, 1956). For example, a child

might be told by a father, “Always stand up for your rights, no matter who, no matter what!” But

the same father tells the same child, “Never question my authority. I am your father, and what I

say goes!” The contradiction inherent in the two messages ensures that no matter what the child

does in relation to the father, it will be wrong. According to the Bateson group, the contradiction,

the father’s failure to admit that there is a contradiction, and the lack of support from other

family members can provide fertile soil for the development of schizophrenia. Actually, there is

very little empirical support for the double-bind theory of schizophrenia. Indeed, there has been a

failure even to establish such communications as reliable phenomena. But the hypothesis was a

remarkably fertile one because it nourished much of the Palo Alto family therapy work. This

illustrates the point that the value of concepts and research does not reside exclusively in their

rightness or wrongness. Their heuristic value—that is, the extent to which they stimulate new

work, new ideas, or new procedures—is also important. Theodore Lidz and his research team

also emphasized the family in the etiology of schizophrenia (Lidz, Cornelison, Fleck, & Terry,

1957a, 1957b). When marriage partners fail to meet each other’s psychological and emotional

needs, one partner may form a pathological alliance with the child, ultimately precipitating the

child’s schizophrenia. Bowen’s (1960) observation of schizophrenic patients who lived together
with their parents in a hospital ward for sustained periods led to the conclusion that the entire

family unit was pathogenic, not just the patient. Ackerman (1958, 1966) reached similar

conclusions. This work is important not because it explained the etiology of schizophrenia (it did

not) but because such work and that of Satir (1967a), Haley (1971), Jackson (1957), and Bell

(1961) gave impetus and direction to the family therapy movement—a movement rich in

technique, theory, and history.

The Concept of Communication

Communication among family members. This communication focus can be seen in what many

regard as the central concept in family therapy—general systems theory. Family therapy deals

with the relationship between the individual family member and the family system. The family is

conceived of as a system, which family therapy seeks to alter in some important way. Many

conceptualize the family as constantly striving to maintain a homeostasis. One person’s

behaviors (e.g., a child’s developmental delays) may shift attention away from a conflictual

marital relationship. Sometimes the family successfully adapts to their particular pattern of

interaction within this system. However, when the system changes (e.g., the child gets older and

is no longer experiencing significant delays), then the system is unable to adjust to a new

homeostasis.

General systems theory would suggest that this “unbalanced” state is the focus for family

therapy.

The therapist achieves positive change by using feedback that alters the way the system functions

and re establishing a new, healthy homeostasis.

Forms and Methods

There is no clear, consensual definition of what constitutes family therapy. Indeed, there is not

even a consensus on who should conduct it. The general procedures of family therapy are carried

on by psychologists, psychiatrists, social workers, counselors, and others. Family therapists and

counselors are trained in several different programs, including clinical psychology, counseling

psychology, psychiatry, social work, family and child development, and education.

All of this, of course, makes for considerable confusion and some squabbling over professional

credentials. Some therapists use family therapy as only one of several techniques; others are

exclusively family therapists. With so little agreement as to who is qualified to conduct family

therapy, is it any wonder that the specific techniques employed (which actually seem to have

much in common) are given such distinctive titles? Thus, we have family therapy, behavioral

family therapy, conjoint family therapy, concurrent family therapy, collaborative family therapy,

network family therapy, structural family therapy, multiple family therapy, and on and on.

Theoretical approaches range from the systemic, to the psychodynamic, to the behavioral, and on

to those that purport to integrate various theoretical practices.

The Goals.

Most family therapists share the primary goal of improving communication within the

family and deemphasize the problems of the individual in favor of treating the problems of the

family as a whole. However, once we get beyond such general statements, there seems to be

some disarray of purposes and goals. For example, many therapists who talk about the family

system still seem to view family therapy as a kind of context in which to solve an individual’s

problems. Seeing the family together becomes a technique (perhaps a more efficient one) for

inducing changes in the individual patient. Other family therapists are devoted to the philosophy

that regarding the family as a unit and working with it as such will enhance that unit.
Although this may benefit the individual members, the real focus is on the family. As in most

enterprises, the largest number of family therapists falls somewhere between the two extremes.

Some General Characteristics. Certain aspects of family therapy differentiate it from the

customary individual therapy. For example, family members have a shared frame of reference, a

common history, and a shared language of connotations that may be foreign to the therapist. The

therapist has to learn the family roles and something about the family’s idiosyncratic subculture.

This information is used to enhance communication or to confront family members. At the same

time, the therapist must remain detached and not become overly identified with one faction of the

family at the expense of another. This can be a difficult and delicate task because family

members will often attempt to use the therapist in their power struggles or in their defenses

against open communication.

A history and assessment process is a typical part of family therapy. The presenting problem

must be stated and understood. It may be that a son is a delinquent or a daughter is sexually

promiscuous.

It is often interesting and diagnostically important to see how different family members construe

the same problem in quite divergent ways. Usually, a family history will be taken. This, too, can

have ramifications. When the family problem is placed in the larger context of information about

the parents’ origins and their early life and marriage, children can often attain improved

communication and understanding. Laying out the entire panorama of family history—its

extended members and their goals, aspirations, fears, and frailties—can lead to deeper

understanding, empathy, and tolerance.

This larger context can promote a shared frame of reference that was not possible earlier. A child

can begin to learn what it meant for the mother to relinquish her own aspirations in favor of the
family or what it meant for the father to experience abuse from his own father. In the controlled

setting of the family therapy room, the parents may, at the same time, remember (via the current

experience of their children) what it was like to encounter peer pressure.

Conjoint Family Therapy

In conjoint family therapy, the entire family is seen at the same time by one therapist. In some

varieties of this approach, the therapist plays a rather passive, nondirective role. In other

varieties, the therapist is an active force, directing the conversation, assigning tasks to various

family members, imparting direct instruction regarding human relations, and so on. Satir (1967a,

1967b) regarded the family therapist as a resource person who observes the family process in

action and then becomes a model of communication to the family through clear, crisp

communication. Thus, Satir viewed the therapist as a teacher, a resource person, and a

communicator.

Such a therapist illustrates to family members how they can communicate better and thereby

bring about more satisfying relationships. The following excerpts from Satir (1967a) clarify the

interaction process for a family.

In conjoint and other forms of family therapy, there are five basic modes of communication

(Satir,

1975): placating (always agreeing, no matter what is going on); blaming (a person’s way of

showing how much he or she can criticize another and thus throw his or her weight around);

super-reasonable (especially characteristic of teachers, whose words may come out “super-

reasonable” but may bear no relationship to how they feel); irrelevant (the words are completely

unrelated to what is going on); congruent (the words relate to what is real). These modes of
communication provide, in a sense, the essence of communication and feeling. They do not

negate the role of cognitions, but they do place the emphasis where Satir believed it belongs.

Other Varieties of Family Therapy

There are many other types of family therapy. The following are a sample of the more commonly

encountered versions.

Concurrent Family Therapy. In concurrent family therapy, one therapist sees all family

members, but in individual sessions. The overall goals are the same as those in conjoint therapy.

In some instances, the therapist may conduct traditional psychotherapy with the principal patient

but also occasionally see other members of the family. As a matter of fact, it is perhaps

unfortunate that the last variation is not used more often as a part of traditional psychotherapy.

Because it is often the case that an individual patient’s problems can be understood better and

dealt with better in collaboration with significant others in the patient’s life, the use of such

arrangements should facilitate the therapeutic process.

Collaborative Family Therapy. In collaborative family therapy, each family member sees a

different therapist. The therapists then get together to discuss their patients and the family as a

whole. As we saw earlier, the use of this approach with child patients was one of the factors that

stimulated the early growth of family therapy. In a variation of this general approach,

cotherapists are sometimes assigned to work with the same family. That is, two or more

therapists meet with the family unit.

Behavioral Approaches to Family Therapy. Some clinicians (e.g., Liberman, 1970; Patterson,

1971) have viewed family relations in terms of reinforcement contingencies and skills training.

The role of the therapist is to generate a behavioral analysis of family problems. This analysis

helps identify the behaviors whose frequency should be increased or decreased as well as the
rewards that are maintaining undesirable behaviors or that will enhance desired behaviors.

Behavioral family therapy then becomes a process of inducing family members to dispense the

appropriate social reinforcements to one another for the desired behaviors. Given the recent

developments in cognitivebehavioral therapy, it is not surprising that this approach has found its

way into the family therapy enterprise. Similar to cognitive-behavioral therapy for the individual,

the family version involves teaching individual family members to self-monitor problematic

behaviors and patterns of thinking, to develop new skills (communication, problem resolution,

negotiation, conflict management), and to challenge interpretations of family events and reframe

these interpretations if necessary (Carlson, Sperry, & Lewis, 1997; N. Epstein, Schlesinger, &

Dryden, 1988).

Multisystemic Therapy. A more recent mode of family therapy, multisystemic therapy (MST)

(Henggeler, 2011; Henggeler & Borduin, 1990; Henggeler, Schoenwald, Borduin, Rowland, &

Cunningham, 2009), was developed as an intervention for juvenile offenders and their families.

The model behind MST assumes that clinical problems are determined by multiple factors,

including the individual, the family, the school environment, and the neighborhood. These

influences are viewed as “systems” of influence within which each person operates. MST sees

the family as the most important link in changing problematic behavior, and this approach is

characterized by several key components:

(a) treatment is delivered in the person’s home, school, or other community locations; (b) MST

therapists are available for consultation 24 hours a day, 7 days a week; (c) the caseloads of MST

therapists are kept intentionally low (4 to 6 families) in order to provide intensive services to

each family; (d) MST therapists serve on a team in order to provide continuity of services and to

be available for back-up should the need arise (Henggeler, 2011). MST uses several evidence
based techniques (e.g., cognitive-behavioral), and both individual and family outcomes are

tracked.

MST has been shown to be both efficacious (compared to no treatment) as well as effective

(Henggeler, 2011). Finally, MST has been modified to address other clinical problems as well,

including youth emotional disturbance, youth substance use disorder, family abuse and neglect,

and child/youth health problems (Henggeler, 2011).

When to Conduct Family Therapy?

There are no hard-and-fast rules as to when family therapy is appropriate and when it is not.Most

often, family therapy is begun with an adolescent as the principal patient. Perhaps the patient’s

problems are so tied up with the family that family therapy is really the only sensible course.

Perhaps the family has impeded therapeutic progress in the past or has resisted the therapist’s

advice. Alternatively, some therapists may conceptualize the adolescents’ symptoms as a signal

that there is trouble somewhere else in the family unit (e.g., a teen’s acting out keeps attention

away from a conflictual marriage; until the marital relationship is addressed, it will be hard to get

the adolescent to reduce disruptive behavior).

Sometimes, family crises, such as the death of a family member, propel the entire family unit

into

pathology almost as one. In some families, there are conflicts over values. For example, an

adolescent who begins to take drugs or becomes totally absorbed in a cult or a different religion

may disrupt the entire family by seeming to undermine its values. In such instances, family

therapy may be a logical recourse.

Finally, significant marital or sexual problems may be resolved best by a form of family therapy.
It can, of course, be difficult to determine whether individual, family, or couples therapy should

be undertaken as a way of working out such problems. However, family therapy or couples

counselling would seem appropriate when the problems do not seem to stem from deep-seated

emotional conflicts but from matters that can be dealt with educationally, including misguided

attitudes, poor knowledge about sexuality, or lack of communication. However, family therapy is

not a cure-all, and it is not always appropriate. Sometimes a family is so disrupted that such

intervention would clearly be doomed to fail. It is also possible that one or more family members

will refuse to cooperate.

In some instances, it quickly becomes clear that a given family member is so disturbed, so

uncooperative, or so disruptive that the entire process of family therapy would be poisoned by

his or her presence. Since family therapy involves several people, one must sometimes consider

its possible use in cost–benefit terms. Although family therapy might benefit the identified

patient of the group, the process could have malignant consequences for some of the other

members. Like individual patients, some families do not possess the psychological strength or

resources to cope with the threatening material that may come out in family therapy sessions.

Deciding when to use family therapy is often a difficult matter that requires careful assessment

and a great deal of clinical sensitivity.