Family Therapy

FAMILY THERAPY

HISTORY OF FAMILY THERAPY Family therapy developed after the

Second World War, Among the first to point out the importance of family therapy were Christian Midelfort (In 1957 he published “The Family In Psychotherapy”) and Nathan Ackerman (In 1958 he published “The Psychodynamics of the Family”).

IN 1960’S By the mid-1960s a number of

distinct schools of family therapy had emerged. From those groups that were most strongly influenced by cybernetics and systems theory, there came strategic therapy, structural therapy, and slightly later, the Milan systems model.

Salvador

Minuchin, psychoanalytically trained psychiatrist largely responsible for the development of the structural school of family therapy. A therapist using this model sees that family problems are related to their structure. 

1970’s By the late-1970s the weight of

clinical experience - especially in relation to the treatment of serious mental disorders - had led to some revision of a number of the original models and a moderation of some of the earlier stridency 

1980’s From the mid-1980s to the

present the field has been marked by a diversity of approaches that partly reflect the original schools, but which also draw on other theories and methods from individual psychotherapy

Family Therapists Leaders Alfred Adler-Rudolf Driekurs-open

forum Child Guidance Clinics Murray Bowen-Multigenerational Model-Triangulation, Differentiation of Self Virginia Satir-Conjoint Family Therapy-Human Validation, Relational Family Therapy 

Carl Whitaker-Experiential

Symbolic Family Therapytherapist or coach influences change Salvador Minuchin-Structural Family Therapy-create structural change Jay Haley-Strategic Family Therapy-solves problems now Cloe Madanes(Wife of Haley)-

EVOLUTION OF FAMILY THERAPY IN INDIA

Family therapy was started in

India about the same time that Nathan Ackermann initiated it in the west. The father of family therapy in India, Dr. Vidyasagar, started treatment with the families for patient who attended the services of the Amritsar mental

According to him involvement of

family decreased hospital stay, increased acceptance of the patient and enhanced family coping (Vidyasagar 1971). Following these rewarding two centres in India- mental health centre Vellore and national institute of mental health and Neuro sciences (NIMHANS) Bangalore started similar

The mental health centre at Vellore

has facilitate for families to live with the patients in small cottages (Varghese 1971) At NIMHANS where the relatives were asked to stay with the patient in open wards (Narayanan et al 1972) The success of these approaches culminated in the building of the family psychiatric centre at NIMHANS in 1977 where the whole family could stay in unit family rooms and undergo

FAMILY PSYCHIATRIC CENTRE AT NIMHANS The family psychiatric centre is

essentially a referral centre and families are seen in therapy either as outpatient or inpatient. The patient and their families are referred from six adult psychiatry units, child guidance centres, and neurological services or outside agencies.

FAMILY A family is defined as two or

more persons who reside together; share economic resources; are related by birth, marriage, or adoption; and or who have a commitment to each other over time. (Walsh 1993)

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NORMAL FAMILY FUNCTIONING Baranhil suggested that healthy

families can be distinguished from dysfunctional ones on the basis of dimensions 

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Identity Process

Individuation Vs Enmeshment Mutuality Vs Isolation 

Change Flexibility Vs Rigidity Stability Vs Disorganization

Information Processing Clear Vs Unclear Or Distorted Clear Vs Unclear Roles or Role

conflict 

Role Structuring Role reciprocity Vs Unclear or

conflicted role Clear Vs Diffuse or Breached Intergenerational boundaries 

ELEMENTS OF ASSESSMENT OF FAMILY FUNCTIONING ELEMENTS OF ASSESSMENT

Communication

FUNCTIONAL

DYSFUNCTIONAL

Clear ,direct, open and honest with congruence between verbal and non verbal

Indirect, vague, controlled , with many double blind messages

ELEMENTS OF ASSESSMENT

FUNCTIONAL

Supportive, loving, Self concept praising, reinforcement approving with behaviors that instill confidence

DYSFUNCTIONAL

Unsupportive, blaming, “put-downs”, refusing to allow self responsibili ty

ELEMENTS OF ASSESSMENT

FUNCTIONAL

Family Flexible, members realistic expectation and individualiz ed

DYSFUNCTIONAL

Judgmental, rigid, controlling , ignoring individualit y

ELEMENTS OF ASSESSMENT

FUNCTIONAL

Handling differences

Tolerant, Attacking, dynamic, avoiding, negotiating . surrendering .

Family Workable, interactional constructive, pattern flexible and promoting needs of all members

DYSFUNCTIONAL

Contradictory, rigid, selfdefeating , and destructive

ELEMENTS OF ASSESSMENT

FUNCTIONAL

DYSFUNCTIONAL

Family climate

Trusting, growth promoting caring, general feeling of well being

Distrusting, emotionally painful, with absence of hope for improvement

HEALTHY FUNCTIONING FAMILIES They

have the ability to communicate thought and feelings.

In the healthy functioning families no

single member dominates or control. Healthy families have a clear, flexible power structure with the most competent members having the most power. Families which are cohesive and adaptable best serve the functions of

DYSFUNCTIONAL FAMILIES Dysfunctional families are often

disengaged (isolated from one another) or enmeshed (overly involved with one another). Multigenerational transmission of problems are common (i.e. Grandmother, mother, daughter all have been sexually and physically abused)

I). COMMUNICATION a) Making Assumptions 

With this behavior one assumes that others will know what is meant by an action or an expression or other hand assumes to know what another member is thinking or feeling without checking to make certain.

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E g: a mother says to her teenage daughter “you should have known that I expected you to clean up the kitchen

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b) Belittling feelings  This Action involves ignoring or minimizing another’s feeling when they are expressed. This encourages the individual to with hold honest feelings to avoid being hurt by the negative response. 

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c) Failing to listen  With this behavior one does not hear what the other individual is saying. This can mean, not hearing the words by “tuning out” what is being said or it can be “selective listening”, in which person hears only a selective part of the message or interprets it in a selective manner. 

E.g. Father explains to son” if the

contract comes through and I get new job, we will have a little extra money and we will consider sending you to US” Johnny relays the message to his friend, “dad says I can go to us” 

d) Communicating Indirectly This usually means that an individual cannot present a message to receiver directly so seeks to communicate through a third person. E.g. father does not want his teenage daughter to see a certain boyfriends but wants to avoid angry response from his daughter if he tells her so. He expresses his 

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Presenting double minded message

e)

Double blind communication conveys a

“damned if I do damned if I don’t” message. E.g. Father tells his son he is spending too much time playing football, and as a result, his grades are falling. He is expected to bring his grades up over next nine weeks or his car will be taken away. When the son tells the father he has quit the football team so he can study more, dad respond angrily “I

II). SELF CONCEPT REINFORCEMENT a) Expressing denigrating remarks These remarks are commonly called “put downs”. Individual receive messages that they are worthless or unloved. E.g. when child spills a glass of milk accidentally, the mother responds “you are hopeless! How 

b)Withholding supportive messages Family members find it difficult provide others with reinforcing and supportive messages. E.g. a little boy was playing cricket, after the game he says to father “did you see my play?” dad, “yes I did, son, if you had been paying better attention you 

c) Taking over  This occurs when one family member fails to permit another member to develop a sense of responsibility and self worth by doing things individually.  E.g. Son says “Dad, I got my driving license last week and today I will drive my car” Dad replied “No , no I will drop you 

III). FAMILY MEMBERS EXPECTATIONS a) Ignoring individuality This occurs when family member s expect others to do things or behave in ways that do not fit with the latter’s individuality or current life situation. E.g. Robert wants to do job in a newspaper company after his studies. But his father asked him to take over the family business founded by his grandfather. Robert sees this as a betrayal of the family. 

b) Demanding proof of love Family members place expectation on others behaviour that are used as standard by which the expecting member determines how much the other member care for him or her. E.g. “if you will not be as I wish you to be, you don’t love me”. 

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IV). HANDLING DIFFERENCES a) Attacking A different opinion can deteriorate in to a direct personal attack and may be manifested by blaming other person. b) Avoiding With this tactic, differences are never acknowledged openly. 

c) Surrendering The person who surrenders in the face of disagreement does so at the expense of denying his or her own needs or rights. 

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V). FAMILY INTERACTIONAL PATTERNS

a) Patterns that causes emotional discomfort

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Interactions

can promote hurt and anger in family members. These interactional patterns include behaviours such as never apologizing or never admitting that one has made mistake, forbidding flexibility in life situations.

b).Factors that intensify problems rather than solve them When problems go unresolved over a

long period of time, it sometimes appear to be easier it to ignore them. If problems of the same type occur, the tendency to ignore them then becomes the safe and predictable pattern of interaction for dealing with this type of situation. This may occur until the problem

intensifies to a point at which it can no longer be ignored.

c) Patterns that are in conflict with each other Some family rules may appear to be functional workable and constructive on the surface but in practice may serve to destroy healthy interactional pattern. 

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Others Marital schism (split) Family in a constant state of disequilibrium through repeated threats of parental separation and communication masks conflicts Parents disqualify each other and join with children excluding the partner. 

Marital skew (twist)  Parental relationship is distorted; Relationship is not under threat, due to one excessively powerful and dominant parent. 

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Pseudo-hostility and Pseudomutuality Disjointed or fragmented communication leads to disrupted interactions. Pressure is put on the child to avoid family relationships. 

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Mystification (confusion) Mystification occurs when one or more family members fail to understand the meaning, purpose of communication from another member; especially a parent. The communication received is often deliberately vague. The vague communication places the mystified person in an inferior position and leads to powerlessness. 

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Triangulation Occurs when a third person is brought into a dyadic relationship to de-intensify a dispute between two people (generally the parents); Communication occurs through a third person. 

The Elephant in the Room

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The problem that no one wants/dares

to talk about and the problem are clearly visible to all involved; Fear of retaliation or negative consequences and shame often keep individuals from discussing the problem. Self blame is common. Victims continue to allow the problem to exist and not be discussed. (E.g. alcoholism, sexual abuse)

Lack of Differentiation Autonomy is important for all individuals. It represents the degree of independence that an individual needs to function apart from others in a system. Fusion is the absence of autonomy; Lack of differentiation leads to enmeshment with others. 

Scapegoating  Families often scapegoat one individual for all of the family’s problems. 

Lack of Boundaries All individuals need boundaries. The absence of boundaries produces unclear limits in terms of what others may or may not say or do to a person. Without boundaries abuse can easily occur. 

FAMILY THERAPY 

DEFINITION

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A type of therapeutic modality in which the focus of treatment is on the family as a unit; it represents a form of intervention in which the members of a family are assisted to identify and change problematic, maladaptive, selfdefeating, repetitive relationship patterns. (Goldenberg & Goldenberg, 2005)

DEFINITION Family therapy is a branch of psychiatry that sees an individual’s psychiatric symptoms as inseparably related to the family in which he lives.  (Susan H McCrone, Anne H Shealy)

DEFINITION A type of psychotherapy designed to identify family patterns that contribute to a behavior disorder or mental illness and help family members break those habits. 

(Webster’s new world medical dictionary)

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GOALS OF FAMILY THERAPY Help families become aware of their

needs. Provide genuine, enduring healing Shift power to parental figures Improve communication Make interpersonal, intrapersonal, and environmental changes Keep substance abuse from moving from one generation to another Provide a neutral forum to solve problems

MAJOR FAMILY THERAPY APPROACHES Structural Strategic Cognitive-Behavioral Social Constructionist Experiential Object Relations Multigenerational Narrative 

BASIC THEORETICAL CONCEPTS Psychodynamic theory 

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Ackerman (1956) introduced the idea of “interlocking pathology”, arguing that the psychopathology of the different members of the family fitted together to produce the family system, which the therapist encountered.

Group therapy 

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The aim is to help the members of the group gain insight through the process of group interaction. The therapist’s role is principally that of facilitator and sometimes interpreter of what is happening between the group members.

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Other theories a) Cybernetics

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Cybernetics is a term that was

introduced by Weiner (1948) to describe regulatory systems that operate by means of feedback loops. This process requires a receptor of some sort, a central mechanism and an effecter. These are connected to form a feedback loop.

Cybernetics concerned with the

study of feedback mechanisms in systems. Two types of feedback loops: Negative, signals the system to restore the status quo Positive, signals the need to modify the system.  Both types result in homeostasis.

b) Systems theory General systems theory was

proposed by Von Bertalanffy, defined ‘a complex of interacting elements’ Hall and Fagan (1956) definedsystem as ‘a set of objects together with the relationship between the objects and between their attributes.’ There are two systems

Closed system is those in which

there is no interaction with the surrounding environment and shows “entropy”. Open systems such as families do not show “entropy”. There is a steady inflow and out flow of relevant information across the boundary of the system.

The relationship between supra systems, systems and subsystems

Ideas and concept of system theory

Families and other social groups are

systems having properties which are more than the sum of the properties of their parts. The operation of such system is governed by certain general rules Every system has a boundary

The boundaries are semi permeable

(something can pass through, others cannot or certain material can pass one way but not the other) Family systems tend to reach relatively, but not totally steady states. Growth and evolution are possible. Change can occur or stimulated in various ways Communication and feedback mechanisms between the parts of a

Events such as the behaviour of

individuals in a family are better understood as examples of circular causality rather than as being based on linear causality. Family systems appear to be purposeful Systems are made up of subsystems and themselves are part of supra systems. 

Characteristics of systems: Circular causality  Linear causality describes the process whereby one event causes another. 2. Boundary  Every system has a boundary, which mark it off from surroundings. They control emotional interchanges, closeness 

1.

3.Feedback 4. Equifinality 

The Process by which an open system maintains the same steady state with differing inputs.

 

c) Learning Theory Respondent conditioning This changes the behavior by altering the circumstances leading up to it. E.g. Pavlov’s classical experiment with dog Operant conditioning It Changes the behaviour by altering the circumstances following it. E.g. If person touches hot and get burned that person is less likely to touch the same thing again. 

d) Communication theories a) It is impossible not to

communicate b) Communication has a relationship aspect c) Punctuation is the important feature of communication d) Communication may be dividing into digital and analogical varieties e) Communication is symmetrical and complementary interaction 

SCHOOLS OF FAMILY THERAPY PSYCHOANALYTICAL FAMILY

THERAPY 



Murray Bowen and Virginia Satir is prominent therapist who has made use of psycho analytical ideas in their work. The family members are encouraged to ‘free associate’, that helps their thoughts to flow freely without conscious censorship,

Psycho

analytic therapist generally makes fewer comments, asks fewer questions and intervenes less actively. They usually refrain also from giving advice and form actively manipulating the families they treat.

BEHAVIORAL FAMILY THERAPY Behavior therapist applies the

principle of learning theory in treatment of families. Change in families conceptualized in terms of respondent conditioning, operant conditioning modeling or cognitive change.

The “behavior analysis”

enables the therapists to develop a plan to alter the contingency or circumstances and cognitions often by direct intervention in the family.

GROUP THERAPY APPROACHES 

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The family therapists have used some of the approaches of group therapy the role of a therapist is facilitator and sometimes interpreter of what is happening between the group members. Family members can certainly learn the value from each other in a group therapy setting.

FAMILY SYSTEM THERAPY MAJOR CONCEPT

Differentiation of self Differentiation of self is the ability to define oneself as a separate being. Healthy families encourage differentiation. A person with well differentiated self recognizes his realistic dependence on others, stay calm and clear headed in enough in the face of conflict, criticism. 

Triangles The concept of triangle refers to a three personal; emotional configuration that is considered the building block of the family systems. Triadic interaction configurations which are the basic building block of any emotional system. When a two-party system becomes unstable because of anxiety, a third person is involved to stabilize 

Nuclear family emotional process The nuclear family emotional process describes the patterns of emotional functioning in single generation. Lower the level of differentiation, the greater the possibility of problem in the future.  

Family projection process Couples

are unable to work through ‘un differentiation’ or fusion that occurs with permanent commitment may when they become parents, project the resulting anxiety on to the children.

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Multigenerational transmission process Interactional patterns are

transferred from one generation to another. Attitudes, values, beliefs, behaviors and patterns of interaction are passed along from the parent to children over many lifetimes. So certain behaviors are existed within a family through multiple generations.

Genograms It gives a picture of three or more

generations (like a family tree) and notes important family dynamics, rules, patterns, mental health issues, etc.

Goal and Technique of the Therapy 1) To increase the level of differentiation

of self, while remaining in touch with the family system. 2) The intense emotional problems within the nuclear family can be resolved only by resolving undifferentiated relationship. 3) Emphasis is given to understanding the past relationship Therapeutic role is that of a “coach” or supervisor

Therapeutic techniques include: 1)

Defining and clarifying the relationship between the family members 2) Helping family members develop one to one relationship with each other and minimizing triangles within the system 3) Teaching family members about the functioning of emotional systems. 4) Promoting differentiation by

THE STRUCTURAL FAMILY THERAPY MAJOR CONCEPTS

Transactional patterns These are the rules that have been established over time that recognize the ways in which family members relate to one another. 

Subsystems Subsystems are smaller elements that make up a large family system. Subsystem can be individuals or can consist of two or more persons united by gender, relationship, generation, purpose. 

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Boundaries  Define the level of participation and interaction among subsystems. Boundaries are appropriate when they permit appropriate contact with others while preventing excessive interference. Clearly defined boundaries promote adaptive function. Maladaptive functioning can occur when boundaries are rigid or diffuse. 

A rigid boundary is characterized

by decreased communication and lack of support and responsiveness. Rigid boundaries prevent subsystem from achieving appropriate closeness or interaction with others in the system, rigid boundaries promote disengagement, or extreme separateness among family members.

Diffuse

boundaries are characterized by dependency or over involvement. In interferes with adaptive functions because of over investment, over involvement, lack of differentiation between certain subsystems. Diffuse boundaries enmeshment or exaggerated connectedness among family members

GOAL AND TECHNIQUES OF STRUCTURAL FAMILY THERAPY Goal of structural family therapy

is to facilitate change in family structure Goal is to restructure the family system to create clear and flexible boundaries

Techniques Joining the family. The therapist must become the part of the family if restructuring is to occur. The therapist joins the family but maintains leadership position. He or she may at different times join various subsystems within the family but ultimately includes the entire family system as a target of 

Focusing Exploring specific areas  

Evaluating the family structure 

Even though a family may come for a

therapy because of behaviour of one family member, the family as a unit is considered problematic. The family structure is evaluated by assessing transactional pattern system flexibility, potential for changing boundaries, family developmental stage and role of the identified patient within the system

Enactment Therapist has family enact an

interaction to enable the family to try different ways of interacting  Intensification  Therapist increases the emotional aspects of interactions Unbalancing      Conscious attempt to form a coalition with one member against another or supporting one member at the expense of another to throw the family system off balance

Restructuring the family. An alliance or contract for therapy is established with the family by becoming an actual member of the family, the therapist is able to manipulate the system facilitate circumstances and experience that can lead to structural change. 

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THE STRATEGIC FAMILY THERAPY The strategic model the family

therapy uses the interactional or communication approach. In this model families considered functional are open system where clear and precise messages, congruent with the situation, are sent and received. Dysfunctional families are viewed as partially closed systems in which communication is vague.

MAJOR CONCEPT Double blind communication 

Double blind communication occur s when a statement is made and succeeded by a contradictory statement. It also occurs when a statement is made and accompanied by nonverbal expression that is inconsistent with the verbal communication. Double blinded communication often results in a “damned if I do damned if I not”.

Pseudo mutuality and pseudo hostility Pseudo mutuality is characterized by façade (image, face) of mutual regard. Pseudo mutuality allows family member to deny underlying fears of separation and hostility. Pseudo hostility is also affixed and rigid style of relating, but the facade being maintained is that of a state of conflict and alienation among family members to deny underling fears of 

Marital schism (split)  Family in a constant state of

disequilibrium through repeated threats of parental separation and communication masks conflicts, Parents disqualify each other and join with children excluding the partner. Mutual trust is absent and competition exists for closeness with the children. Often partner establishes an alliance with his or her parents against the spouse. Children lack appropriate role

Marital skew (twist)  Parental relationship is

distorted; Relationship is not under threat, due to one excessively powerful and dominant parent. There is a lack of equal partnership. The marriage remains intact as long as the passive partner allows the domination to continue. Children also lack role models when a

GOAL AND TECHNIQUES OF THERAPY To create changes in destructive

behaviors and communication patterns among family members.

Therapeutic techniques involve: 1.

Paradoxical intervention A paradox can be called a contradiction in therapy or “prescribing the symptom.” The therapist requests the family to continue to engage in the behavior that they are trying to change.

Reframing (positive

reframing. ) Re labeling a problematic behaviour by

putting into a new, more positive perspective that emphasizes its good intention. With reframing, the behaviour may not actually change, but the consequences of the may change owing to a change in meaning attached to the behaviour 

NARRATIVE FAMILY THERAPY

The goal of therapy is to

transform clients’ stories and alter their identities. The centerpiece of therapy is questioning.

APPLICATIONS OF FAMILY THERAPY Common child psychiatric

disorders Child abuse Eating disorders, esp. anorexia nervosa Depression Schizophrenia Marital and family distress  

BASIC CRITERIA FOR EMPLOYING FAMILY THERAPY

Evidence of malfunctioning family group Evidence that family dysfunction is

related to the problems for which help is being sought. When a change is desired in the way a family functions Separation difficulties Family functions at the paranoid schizoid level Severely disorganized families,

DIFFERENCE BETWEEN INDIVIDUAL THERAPY AND FAMILY THERAPY INDIVIDUAL THERAPY

FAMILY THERAPY

View the individual as Relationships are the the agent of change agents of change Ask, why?

Ask, what?

Think linearly (A causes B)

Think circularly (A and B mutually influence one another.)

INDIVIDUAL THERAPY

FAMILY THERAPY

Treat the “mind”

Treat the interactions between individual

Focus on the past

Focus on the present

Focus on content

Focus on process

Recognize individual developmental trajectories

Recognize individual and familial development

Obtain accurate diagnosis DSM IV

Explore System for family process & rules

INDIVIDUAL THERAPY

FAMILY THERAPY

Begin Therapy right now Invite in parents, siblings Focus on : causes, purposes, processes

Focus: family relationships

Concern with individual Concern trans experience & generational meanings, perspective rules Intervene to help Intervene to change individual learn to cope context within family system

LIMITATIONS OF FAMILY THERAPY Individual psychological factors

were neglected. Lack of clear operationalization of the constructs for research purposes Feminist Critique Race/Ethnic Diversity

ROLE OF NURSE Nurse should be well prepared to

enhance family functioning in traditional clinical setting and nontraditional setting The knowledge skill and creativity of the nurse enhances family compliances Nurses need to integrate theory and interventions into clinical programs, advocate for family and third party reimbursement for family

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