Family therapy

Definition

Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family. It may be conducted by a pair or team of therapists. In many cases the team consists of a man and a woman in order to treat gender-related issues or serve as role models for family members. Although some forms of family therapy are based on behavioral or psychodynamic principles, the most widespread form is based on family systems theory. This approach regards the family, as a whole, as the unit of treatment, and emphasizes such factors as relationships and communication patterns rather than traits or symptoms in individual members.

Family therapy is a relatively recent development in psychotherapy. It began shortly after World War II, when doctors, who were treating schizophrenic patients, noticed that the patients' families communicated in disturbed ways. The doctors also found that the patients' symptoms rose or fell according to the level of tension between their parents. These observations led to considering a family as an organism or system with its own internal rules, patterns of functioning, and tendency to resist change. The therapists started to treat the families of schizophrenic patients as whole units rather than focusing on the hospitalized member. They found that in many cases the family member with schizophrenia improved when the "patient" was the family system. (This should not be misunderstood to mean that schizophrenia is caused by family problems, although family problems may worsen the condition.) This approach of involving the entire family in the treatment plan and therapy was then applied to families with problems other than the presence of schizophrenia.

Family therapy is becoming an increasingly common form of treatment as changes in American society are reflected in family structures. It has led to two further developments: couples therapy, which treats relationship problems between marriage partners or gay couples; and the extension of family therapy to religious communities or other groups that resemble families.

Purpose

Family therapy is often recommended in the following situations:

• Treatment of a family member with schizophrenia or multiple personality disorder . Family therapy helps other family members understand their relative's disorder and adjust to the psychological changes that may be occurring in the relative.
• Families with problems across generational boundaries. These would include problems caused by parents sharing housing with grandparents, or children being reared by grandparents.
• Families that deviate from social norms (common-law relationships, gay couples rearing children, etc.). These families may not have internal problems but may be troubled by outsiders' judgmental attitudes.
• Families with members from a mixture of racial, cultural, or religious backgrounds.
• Families who are scapegoating a member or undermining the treatment of a member in individual therapy.
• Families where the identified patient's problems seem inextricably tied to problems with other family members.
• Blended families with adjustment difficulties.

Most family therapists presuppose an average level of intelligence and education on the part of adult members of the family.

Precautions

Some families are not considered suitable candidates for family therapy. They include:

• families in which one, or both, of the parents is psychotic or has been diagnosed with antisocial or paranoid personality disorder,
• families whose cultural or religious values are opposed to, or suspicious of, psychotherapy,
• families with members who cannot participate in treatment sessions because of physical illness or similar limitations,
• families with members with very rigid personality structures. (Here, members might be at risk for an emotional or psychological crisis),
• families whose members cannot or will not be able to meet regularly for treatment,
• families that are unstable or on the verge of breakup.

Description

Family therapy tends to be short-term treatment, usually several months in length, with a focus on resolving specific problems such as eating disorders, difficulties with school, or adjustments to bereavement or geographical relocation. It is not normally used for long-term or intensive restructuring of severely dysfunctional families.

In family therapy sessions, all members of the family and both therapists (if there is more than one) are present at most sessions. The therapists seek to analyze the process of family interaction and communication as a whole; they do not take sides with specific members. They may make occasional comments or remarks intended to help family members become more conscious of patterns or structures that had been previously taken for granted. Family therapists, who work as a team, also model new behaviors for the family through their interactions with each other during sessions.

Family therapy is based on family systems theory, which understands the family to be a living organism that is more than the sum of its individual members. Family therapy uses "systems" theory to evaluate family members in terms of their position or role within the system as a whole. Problems are treated by changing the way the system works rather than trying to "fix" a specific member. Family systems theory is based on several major concepts:

The identified patient

The identified patient (IP) is the family member with the symptom that has brought the family into treatment. The concept of the IP is used by family therapists to keep the family from scapegoating the IP or using him or her as a way of avoiding problems in the rest of the system.

Homeostasis (balance)

The concept of homeostasis means that the family system seeks to maintain its customary organization and functioning over time. It tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change.

The extended family field

The extended family field refers to the nuclear family, plus the network of grandparents and other members of the extended family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviors, and other issues.

Differentiation

Differentiation refers to the ability of each family member to maintain his or her own sense of self, while remaining emotionally connected to the family. One mark of a healthy family is its capacity to allow members to differentiate, while family members still feel that they are "members in good standing" of the family.

Triangular relationships

Family systems theory maintains that emotional relationships in families are usually triangular. Whenever any two persons in the family system have problems with each other, they will "triangle in" a third member as a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that maintains family homeostasis. Common family triangles include a child and its parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.

Preparation

In some instances the family may have been referred to a specialist in family therapy by their pediatrician or other primary care provider. It is estimated that as many as 50% of office visits to pediatricians have to do with developmental problems in children that are affecting their families. Some family doctors use symptom checklists or psychological screeners to assess a family's need for therapy.

Family therapists may be either psychiatrists, clinical psychologists, or other professionals certified by a specialty board in marriage and family therapy. They will usually evaluate a family for treatment by scheduling a series of interviews with the members of the immediate family, including young children, and significant or symptomatic members of the extended family. This process allows the therapist(s) to find out how each member of the family sees the problem, as well as to form first impressions of the family's functioning. Family therapists typically look for the level and types of emotions expressed, patterns of dominance and submission, the roles played by family members, communication styles, and the locations of emotional triangles. They will also note whether these patterns are rigid or relatively flexible.

Preparation also usually includes drawing a genogram, which is a diagram that depicts significant persons and events in the family's history. Genograms also include annotations about the medical history and major personality traits of each member. Genograms help in uncovering intergenerational patterns of behavior, marriage choices, family alliances and conflicts, the existence of family secrets, and other information that sheds light on the family's present situation.

Risks

The chief risk in family therapy is the possible unsettling of rigid personality defenses in individuals, or couple relationships that had been fragile before the beginning of therapy. Intensive family therapy may also be difficult for psychotic family members.

Normal results

Normal results vary, but in good circumstances, they include greater insight, increased differentiation of individual family members, improved communication within the family, loosening of previously automatic behavior patterns, and resolution of the problem that led the family to seek treatment.

Key Terms

Blended family

A family formed by the remarriage of a divorced or widowed parent. It includes the new husband and wife, plus some or all of their children from previous marriages.

Differentiation

The ability to retain one's identity within a family system while maintaining emotional connections with the other members.

Extended family field

A person's family of origin plus grandparents, in-laws, and other relatives.

Family systems theory

An approach to treatment that emphasizes the interdependency of family members rather than focusing on individuals in isolation from the family. This theory underlies the most influential forms of contemporary family therapy.

Genogram

A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the members understand their problem(s).

Homeostasis

The tendency of a family system to maintain internal stability and resist change.

Identified patient (IP)

The family member in whom the family's symptom has emerged or is most obvious.

Nuclear family

The basic family unit, consisting of father, mother, and their biological children.

Triangling

A process in which two family members lower the tension level between them by drawing in a third member.