SEMINAR HANDOUT

Topic- Family Therapy: Origin, Indications & Contraindications

Presenter: Rituparna Das

Supervisor: Dr. Soma Sahu, Assistant Professor
Date: 19th May, 2022
Time: 2.30 P.M.
POST GRADUATE INSTITUTE OF BEHAVIOURAL AND
MEDICAL SCIENCES, RAIPUR
 Family Therapy

Family Therapy- It is a form of psychotherapy that focuses on the improvement of interfamilial

relationships and behavioral patterns of the family unit as a whole, as well as among individual
members and groupings, or subsystems, within the family. Family therapy includes a large
number of treatment forms with diverse conceptual principles, processes and structures, and
clinical foci.
Origin & Evolution of Family Therapy

Family therapy emerged, in the years following the Second World War, as a novel means of
helping people with psychiatric, emotional and relationship problems. While the family
environments often appeared problematic, whether they were considered cause or effect of the
subjects’ difficulties the ‘solution’ favored was often to remove the patient/client from their
family and local environment to a different setting. The treatment of the individual sufferer,
whether living at home or not, continued to be focused on the individual rather than the family
group before the Second World War, and up to the 1950s. The pioneers of family therapy, on the
other hand, rejected this approach. Instead, they advocated tackling the family and other
environmental problems in the setting where they operated.

Family therapy’s early years

Family therapy was but one of the several new therapeutic approaches that emerged during the
1950s. Chlorpromazine was the first antipsychotic to become available. At about the same time
antidepressant drugs made their appearance. The first of these was a ‘tricyclic’ compound named
“imipramine”. Then behavior therapy, and its close relative, cognitive behavioral therapy, joined
the throng of new treatments. Christian Midelfort’s book “The family in psychotherapy” was
published in 1957.
By the same time Nathan Ackerman, one of the foremost of the family therapy pioneers said
that, by acquiring skills in working with whole family groups, we would come to add ‘a new
dimension to our insights into mental illness as an ongoing process that changes with time and
the conditions of group adaptation’. Ackerman published his second book “Treating the
troubled family” in 1966, was one of the first books focusing on the treatment of ‘the family as
an organic whole’.
The Mental Research Institute (MRI) was founded by Don Jackson, in Palo Alto, California,
in 1959. It had an important role in the development of family therapy, and continued after
Bateson’s group disbanded in 1962.
Theodore Lidz (Lidz & Lidz, 1949) began studying the families of patients with schizophrenia
at Johns Hopkins Hospital, Baltimore, in 1941, later moving to Yale University. He introduced
the concepts of schism, the division of the family into two antagonistic and competing groups;
and skew, where there is one partner in the marriage who dominates the family to a striking
degree, as a result of serious personality disorder in at least one of the partners.
Wynne and his colleagues concluded that the families of ‘potential schizophrenics’ are
characterized by pseudo mutuality and consequently have rigid, unchanging role structures to
which they cling, as they feel they are essential.
Bowen (1960) saw schizophrenia as a process requiring three generations to develop. Laing also
studied the families of patients with schizophrenia. He was interested in the process of
mystification (see Laing, 1965), which he linked with the ‘six ways to drive the other person
crazy’ proposed by Searles (1959).

The 1960s
Despite having had psychoanalytic training, Jackson increasingly concentrated on the study and
treatment of interpersonal processes.
Jay Haley took a directive approach in treating families. Strategies of psychotherapy (Haley,
1963) set out Haley’s early position, and a series of publications have since traced his
development as one of the most creative of the fathers of family therapy (Haley, 1967,). He also
saw many family problems as due to confused or dysfunctional hierarchies within the family. So
he worked actively to get families to do something different that would help them change their
dysfunctional ways of interacting.
During the 1960s, Murray Bowen expanded his work by tackling families with children who
had problems other than schizophrenia. He also described what he called the undifferentiated
ego mass, observing that in many troubled families members often lacked separate identities
(Bowen, 1961).
Ackerman continued his work throughout the 1960s, and in 1961, he and Jackson co-founded
Family Process, the first journal devoted to family therapy.
Virginia Satir joined Jackson shortly after he founded the MRI. Her book “Conjoint family
therapy “(Satir, 1967) influenced many therapists. She was particularly interested in the
communication of feelings in families and in the personalities and development of the
individuals in the family.
A ‘family psychiatric unit’ was established at the Tavistock Clinic, London, in the late 1940s.
Under the direction of Dicks (1963, 1967), the staff of this unit worked mainly with marital
couples who were having problems in their relationships.

The 1970s
In 1971, the American Association for Marriage and Family Therapy (AAMFT) developed
the first set of standards for the approval of family therapy training programmes.
Papp (1977) edited Family therapy: Full length case studies, which presented the work of 12
prominent family therapists, including herself. The book provides a snapshot of family therapy in
the 1970s and illustrates the diversity of approaches used by therapists at that time.
Hoffman’s (1981) Foundations of family therapy: A conceptual framework for systems change
surveyed the state of family therapy as the 1970s came to an end.
The Philadelphia Child Guidance Clinic, under Salvador Minuchin’s leadership, became one
of the world’s leading family therapy centers. The child guidance clinic was closely associated
with the Children’s Hospital of Philadelphia, facilitating the joint study of children with
psychosomatic disorders and their families. This led to the book Psychosomatic families:
Anorexia nervosa in context (Minuchin, Rosman, & Baker, 1978).
During the 1970s Murray Bowen continued to refine his theory, He ceased treating the families
of schizophrenics, applying his methods instead to a wider range of problems.
Mara Selvini played a major role in setting up the Institute for Family Study. She was one of the
four psychoanalytically trained psychiatrists who was included in the ‘Milan Group’.
Among the contributions to family therapy made by the Milan group were their techniques of
‘circular interviewing’ and ‘triadic questioning’, whereby the therapist asks a third family
member about what goes on between two others; their concept of developing hypotheses about
the functioning of a family in advance of the interview and then devising questions to test the
hypotheses; developing a better understanding of how the ‘symptom’ is connected to the
‘system’; and their way of structuring each therapy session.

The 1980s
New concepts and techniques also continued to emerge. These included the ‘narrative’
approach and the technique of ‘externalizing’ problems of the creative Australian therapist,
Michael White (White & Epston, 1990); various cognitive approaches to treating family
problems, and the ‘systematic family therapy’ of Luciano L’Abate (1986).
Another development was brief ‘solution-focused’ therapy. It describes the work of the Brief
Family Therapy Centre (BFTC). The work at BFTC owed a lot to the MRI approach as well.
This book describes a quite stylized approach to therapy, employing a therapy team, one member
being the ‘conductor’, the person who goes into the room with the family, the others being the
observers behind the one-way screen. The team, observers and conductor devise interventions,
which are often tasks for the family to perform that may enable the family see their problems in a
different light. In other words, the problems are ‘reframed’.
During the 1980s, books appeared focusing on various particular aspects of family therapy such
as ‘transgenerational patterns’ (Kramer, 1985); ‘doing therapy briefly’ (Fisch, Weakland, &
Segal, 1982); the use of rituals (ImberBlack, Roberts, & Whiting, 1988); ‘families in perpetual
crisis’ (Kagan & Schlosberg, 1989); and the use of family systems principles in family medicine
(Glenn, 1984; Henao & Grose, 1985) and in nursing.

1990s and the new millennium

Family therapy now has an established place among the psychotherapies. Steinglass (1996), in
his journal “Family Process” mentioned family therapy’s ‘ups and downs’.
During the 1990s, interest increased in the application of cognitive behavioral methods in family
therapy. In Understanding and helping families: A cognitive-behavioral approach, Schwebel and
Fine (1994) described and discussed the ‘cognitive-behavioral family model’ (CBF). The
basis of this approach is the assumption that the ‘experiences, thoughts, emotions and behaviors
(of individuals) are heavily shaped by the manner in which they cognitively structure their
world’. They also described about family schema.
Family therapy is also being applied to an ever-widening range of family types and ethnic
groups. For example, the September 2005 issue of Contemporary Family Therapy was devoted
to Treating Indian Families: In India and Around the World.
Nurturing queer youth: Family therapy transformed (Fish & Harvey, 2005) addressed the issue of
working with ‘sexual minority youth’. The authors prefer this term or, more simply, queer youth,
to terms such as gay, lesbian, bisexual and transgendered, because they consider the former term
to be more inclusive. They point out that young people are ‘coming out’, to themselves, to their
families and to their wider environment at ever younger ages. Fish and Harvey discuss the
challenge of working with such young people and their families.
The second edition of Family therapy in changing times, by Gorell Barnes (2004) took a broad
look at the diversity of family forms created by such things as- new cohabitation and marriage
patterns, the choice by some of lone parenthood, divorce and re-partnering, gay and lesbian
parenting, migration, cultural diversity.
The 1990s saw the emergence of the ‘post-modern’ approach to therapy. This was well
described in Harlene Anderson’s (1997) book Conversation, language, and possibilities.
Anderson (1997) goes on to provide one of the clearer descriptions of the post-modern approach
to therapy, that is no longer is the therapist ‘an objective, neutral, and technical expert who is
knowledgeable about pathology and normalcy and who can read the inner mind of a person like a
text’. By contrast, in the collaborative approach the focus ‘is on a relational system and process
in which client and therapist become conversational partners in the telling, inquiring,
interpreting, and shaping of the narratives’.
Johnson provides a fuller discussion of emotionally focused therapy (EFT) in the book Hold me
tight (2008), with many illustrations of this therapeutic approach. Johnson emphasizes the role of
emotional bonding in human relationships, which she considers as important in adult
relationships as in those that develop between children and their parents.
Gottman claims to have developed a ‘revolutionary’ method of helping couples. Its essence is
the reinforcement of the positive aspects of a relationship. Gottman has also identified four
emotional reactions which, he says, are destructive and, therefore, may lead to divorce. These are
criticism, defensiveness, stonewalling and contempt, the latter being the most important.
Gottman and his wife Dr. Julie Gottman founded the non-profit The Relationship Research
Institute and the for-profit Gottman Institute, which is concerned with training therapists.
There is vigorous debate about whether an emphasis on the common factors in effective therapy
(client characteristics and extra-therapeutic factors, the therapeutic relationship, the therapist’s
model or technique or hope and expectancy) should be emphasized over the specific factors
found in particular therapeutic approaches (Sexton & Ridley, 2004; Sprenkle & Blow, 2004).
The field of family therapy is a lively one, with help being provided to many who suffer from a
variety of emotional, relationship and other difficulties. At the same time, its practitioners
continue to develop new treatment methods and to evaluate those in current use.

The Stages Of Family Therapy

The Initial Telephone Call-
 The goal of the initial contact is to get an overview of the presenting problem and to arrange
for the family to come for a consultation. Although the initial phone call should be brief, it’s
important to establish a connection with the caller as a basis for engagement.
 Then schedule the first interview, specifying who should attend (usually everyone in the
household) and the time and place.
 When the caller presents the problem as limited to one person, a useful way to broaden the
focus is to ask how the problem is affecting other.

First-Session Checklist-
1. Make contact with each member of the family, and acknowledge his or her point of view
about the problem and feelings about coming to therapy.
2. Establish leadership by controlling the structure and pace of the interview.
3. Develop a working alliance with the family by balancing warmth and professionalism,
empathy and respect.
4. Focus on specific problems and attempted solutions. Develop hypotheses about unhelpful
interactions around the presenting problem. Also notice helpful interactions that can support
the family in moving forward.
5. Offer a treatment contract that acknowledges the family’s goals and specifies the therapist’s
framework for structuring treatment and Invite questions.

Early-Phase Checklist-
1. Identify major conflicts and bring them into the consulting room.
2. Develop a hypothesis and refine it into a formulation about what the family is doing to
perpetuate (or fail to resolve) the presenting problem.
3. Assign homework that addresses problems and the underlying structure and dynamics
perpetuating them.
4. Challenge family members to see their own roles in the problems that trouble them.
5. Push for change, both during the session and between sessions at home.
6. Make use of supervision to test the validity of formulations and effectiveness of interventions

Middle-Phase Checklist-
1. Use intensity to challenge family members, ingenuity to get around resistance, and empathy
to get underneath defensiveness.
2. Avoid being so directive that family members don’t learn to improve their own ways of
relating to each other.
3. Foster individual responsibility and mutual understanding.
4. Make certain that efforts to improve relationships are having a positive effect on the
presenting complaint.
5. When meeting with subgroups, don’t lose sight of the whole family picture, and don’t neglect
any individuals or relationships—especially those contentious ones that are so tempting to
avoid.

Termination Checklist-
1. Has the presenting problem improved?
2. Is the family satisfied that they have achieved what they came for, or are they interested in
continuing to learn about themselves and improve their relationships?
3. Does the family have an understanding of what they were doing that wasn’t working and
how to avoid the recurrence of similar problems in the future?
4. Do minor recurrences of problems reflect lack of resolution of some underlying dynamic or
merely that the family has to readjust to function without the therapist?
5. Have family members developed and improved relationships outside the immediate family
context as well as within it?

Family assessment

The Presenting Problem- In exploring the presenting complaint, the goal for a systemic
therapist is to question the family members about who has the problem and why. Helpful
questions convey respect for family members ‘feelings but skepticism about accepting the
identified patient as the only problem in the family, to explore and open things up, invite new
ways of seeing the problem, or the family generally.
The next thing to explore is the family’s attempts to deal with the problem: What have they
tried? What’s been helpful? What hasn’t been helpful? Has anyone other than those present been
involved in trying to help (or hinder) with these difficulties etc.

Understanding the Referral Route- It’s important to know whether a family’s participation is
voluntary or coerced, whether all or only some of them recognize the need for treatment, and
whether other agencies will be involved with the case.

Identifying the Systemic Context- Regardless of who a therapist elects to work with, it’s
imperative to have a clear understanding of the interpersonal context of the problem. Who all is
in the family, Are there important figures in the life of the problem who aren’t present etc.
Stage of the Life Cycle- Most families come to treatment not because there’s something
inherently wrong with them but because they’ve gotten stuck in a life-cycle transition. Always
consider life-cycle issues in formulating a case.

Family Structure- Regardless of what approach a therapist takes, it’s wise to understand the
family’s structure. What are the subsystems and the nature of the boundaries between them?
What is the status of the boundary around the couple or family? What triangles are present?

Communication- Although some couples come to therapy saying they have “communication
problems” (usually meaning that one person won’t do what the other one wants), working on
communication has become a cliché in
family therapy. But because communication is the vehicle of relationship, all therapists deal with
it.

I) Systemic Family Therapy- Key systemic approaches include- Structural family therapy,
Strategic family therapy, Social constructionist approaches and Solution Focused Brief Therapy.
Systems theory- Systems theory had its origins in the 1940s. According to systems theory, the
essential properties of living systems arise from the relationships among their parts. These
properties are lost when the system is reduced to isolated elements. The whole is always greater
than the sum of its parts. Thus, from a systems perspective, it would make little sense to try to
understand a child’s behavior by interviewing him or her without the rest of the child’s family.
To begin with, the shift from looking at individuals to considering the family as a system means
shifting the focus to patterns of relationship.
For example- If a father scolds his son, his wife tells him not to be so harsh, and the boy
continues to misbehave, a systemic analysis would concentrate on this sequence, for it is this
sequence of interaction that reveals how the system functions.

II) Social Constructivism- Systems theory taught us to see how people’s lives are shaped by
their interchanges with those around them. In focusing on patterns of interaction, however,
Systems theory left something out—actually, two things: how family members’ beliefs affect
their actions and how cultural forces shape those beliefs.
Constructivism- It is the modern expression of a philosophical tradition that goes back as far as
the eighteenth century. According to Kelly, we make sense of the world by creating our own
constructs of the environment. We interpret and organize events, and we make predictions that
guide our actions on the basis of these constructs. constructivism shifted the focus to the
assumptions people have about their problems. Meaning itself became the target. The goal of
therapy changed from interrupting problematic patterns of behavior to helping clients find new
perspectives in their lives.
For example- The first application of constructivism in family therapy was the technique of
reframing—relabeling behavior to shift how family members respond to it. Clients respond very
differently to a child seen as
“hyperactive” than to one perceived as “misbehaving.” Likewise, the parents of a rebellious
ten-year-old will feel better about themselves if they become convinced that, rather than being
“ineffectual disciplinarians,” they have an “oppositional child.”

Schools of Family Therapy

1. Bowenian
2. Structural
3. Strategic
4. Experiential
5. Psychoanalytic
6. Cognitive- Behavioral
7. Solution Focused Brief Family Therapy
8. Multiple Family Group Therapy
9. Multisystemic Family Therapy

Bowenian Family Therapy

Bowen’s theory focuses on the balance of two forces. The first is togetherness and the second is
individuality. Too much togetherness creates fusion and prevents individuality, or developing
one’s own sense of self. Too much individuality results in a distant and estranged family. Bowen
believed that optimal family development occurs when family members are differentiated, feel
little anxiety regarding the family, and maintain a rewarding and healthy emotional contact with
each other. Bowen introduced eight interlocking concepts to explain family development and
functioning.

1. Bowen Family System Theory- The initial 6 concepts are-

 Triangle
 Nuclear family emotional process
 Family projection process
 Differentiation of self
 Multigenerational transmission process
 Sibling position.

1.1 Triangles- The concept of Triangle addresses the behavior of the two person relationship
when stressed. When anxiety is low, a two person, togetherness oriented relationship can appear
stable with a warm, positive feeling tone. With an increase in anxiety, tension in the relationship
increase and may appear as conflict, distant or some other form of relationship discomfort. The
outsider may experience varying degree of discomfort and may seek to involve in the
relationship. When the anxiety is high the outsider occupies the preferred position, with
moderate anxiety, the triangles tends to have two comfortable sides and one conflictual side.

If the anxiety is high enough, it cannot be contained within a single triangle. It spills over, so to
speak, in to the series of interlocking triangles that comprises the family system as more and
more people become involving in it.

Case Example- Jeanette and Tim have been married for seven years when they seek couples
counseling. Tim complains to the therapist that each time the couple argues, Jeanette phones her
mother, Barbara, to vent. Tim has become uncomfortable around his mother-in-law, feeling as
though Barbara has formed a negative opinion of him as a result of these conversations. Tim also
feels that the involvement of Barbara makes it more difficult for him and his wife to work on
their marriage together. Jeanette insists that she has tried and failed to talk things out with her
husband and that she needs her mother’s input in order to resolve her feelings. Jeanette has
shared her concerns that if she does not speak to her mother, she will become more depressed
and it will negatively affect the marriage.

Case example treatment-

 Facilitating awareness of how the emotional system functions.

 Increasing levels of differentiation, where the focus is on making changes for the self
rather than on trying to change others.

[Note: It is typical for families to attempt to involve the therapist in the triangulation by trying to
get them to agree with one side. It is the therapist’s job to ensure that they are NOT pulled into a
triangulation as this will prevent the family members from being able to address and resolve
their conflicts.]

1.2 Nuclear Family Emotional Process- There are 4 mechanism or patterns of behavior that
come into effect to contain anxiety in the nuclear family. A particular family may use one
mechanism predominantly or a mixture of all. Each mechanism can absorbed or bind an amount
of anxiety in a relationship.

1.2.1 Emotional Distance- This refers to the reactive efforts of people to find relief from the
emotional discomfort of too much closeness and the distancing represents a reaction to the
discomfort of an intense emotional contact with the other. It can be achieved either through
actual physical distance or through internal mechanism in each person that work against
emotional contact. When the discomfort of emotional distance is great enough, people seek
closeness elsewhere in the pattern of the triangle described above. This can take the form of a
affaire or a major emotional investment in a carrier or a cause, or the distance may shift in to a
child or focus on some other mechanism
1.2.2 Marital Conflict- It represents a high degree of emotional reactivity in each partner to the
other. Partners in marital conflict tend to spend much of their thinking time focused on the
“unreasonable” and “uncaring” qualities of each other. The conflict often is followed by distance
which each justifies on the basis of other’s behavior. Therapy often will be sought, through a
range of outside involvement. Logical resolution of an issue hardly settles matters since the
conflictual couple promptly will introduce a new issue. The focusing of some emotional intensity
on a partner can relieve a child who might otherwise become its target.

1.2.3 Dysfunction in a spouse- There are continual compromises in which a partner yields to the
wishes of the others to preserve relationship harmony. Over time this can create a pattern of one
spouse gradually functioning with increasing responsibility for the other, who gradually yields
responsibility for self, which results an over-functioning & under-functioning reciprocity. If
stress is moderate, this mechanism can work quite well to contain anxiety. When anxiety is
intense, however the pattern can lead to appearance of symptom in the spouse who has yielded
adaptively the greater sense of self to preserve harmony in the relationship. When stress beyond
tolerance, however the apparent over-functioner will collapse, often suddenly, into dysfunction.

1.2.4 Impairment of Children- It involves shifting of parental anxiety towards one or more
children. In this parental emotional intensity is directed towards a particular child. This maternal
concern often becomes evident in a highly protective posture toward the child and a tendency to
act and decide for the child. The father characteristically supports the mother in her focus or
withdraws from it. Initially this process is driven by anxiety in the parent rather than a problem
in the child. The child in this position develops a heightened sensitivity to emotional forces in the
family and particularly to the mother. The outcome for the child is a higher degree of emotional
and intellectual systems fusion than that of less involved siblings. In its more intense forms it
may be difficult for the child to function away from home. The child can come to seek out
closeness and at the same time react intensely to it, making other life relationships more intense
and difficult.

1.3 Family Projection Process- Parental reactions and behaviors are not the same towards each
child no matter how much the parents insist they treat each child equally. Those differences in
parental behavior have important implications for the functioning of the children involved. The
projection process is rooted in the parent’s anxiety about the child, often present even before the
child’s birth. Mother’s anxiety appears to be more influential than that of the father. Example-
The parents may see a child as more sensitive or more delicate than their other children. The
father may work to “toughen up” the child, while the mother “protects” the child from the father
and the world. The child begins to act in a manner that confirms the parental fears and the
process can intensify. In short the parents emotionally shaped perception of what the child is like
eventually becomes reality to the child. The same parents may have quite differently with other
children in the family, free of the anxiety that shapes their action toward the focused child, the
parents are better able to allow the other siblings to develop their own direction in life.
1.4 - Differentiation of Self- Families and other social groups tremendously affect how people
think, feel, and act, but individuals vary in their susceptibility to a “groupthink” and groups vary
in the amount of pressure they exert for conformity. The less developed a person’s “self,” the
more impact others have on his functioning and the more he tries to control, actively or
passively, the functioning of others. The basic building blocks of a “self” are inborn, but an
individual’s family relationships during childhood and adolescence primarily determine how
much “self” he develops. Once established, the level of “self” rarely changes unless a person
makes a structured and long-term effort to change it.

Case Example- Mark is a 21 year old male who is currently attending a liberal arts college. He
is completing his junior year and is in discussions with his family about his future plans. Both of
Mark’s parents are doctors and they have encouraged Mark throughout his education to focus on
math and sciences. Mark is aware of their expectations but has been procrastinating in taking the
steps necessary to apply to medical school, including taking the MCAT, taking some required
classes and looking into potential schools. Mark’s parents are getting increasingly angry at him
for his procrastination and family arguments have been increasing. Mark is seeking treatment
due to an increase in anxiety, poor sleep and decreased functioning in school, including missing
classes, missing assignments and poor grades.

1.5 Emotional Cutoff- The mechanism of cutoff can be external or internal. The individual may
live far from the family and carefully structure “day visits” once or twice in a year or may live in
a close proximity to the family and use a series of internal mechanism to shut off emotional
contact. The overall outcome of either set of mechanisms is the avoidance of any highly
emotional area of family past or present. People distance themselves from the family to avoid
emotional intensity, yet their reactive need for closeness and intense emotionality leads them into
relationships to which they are equally reactive. For example- people can cut-off from the
intensity of marriage into an affair or into an intense psychotherapeutic relationship or into
religion.

1.6 Sibling Position- Employing Walter Toman's (1976) sibling profiles, Bowen considered that
sibling position could provide useful information in understanding the roles individuals tend to
take in relationships. For example, his profiles describe eldest children as more likely to take on
responsibility and leadership, with younger siblings more comfortable being dependent and
allowing others to make decisions. Middle children are described as having more flexibility to
shift between responsibility and dependence and 'only' children are seen as being responsible,
and having greater access to the adult world. Bowen was especially interested in which sibling
position in a family is most vulnerable to triangling with parents. It may be that a parent
identifies strongly with a child in the same sibling position as their own. Helping the client
understand and think beyond the limitations of their own sibling position and role is a goal of
Bowenian family of origin work. Clients are encouraged to consider how assumptions about
relationships are fuelled by their sibling role experience.
1.7 Multi-generational Transmission Process- Emotional forces in families operate over the
years in patterns. Bowen originally used the term undifferentiated family ego mass to describe
an excess of emotional reactivity, or fusion in families. Lack of differentiation in a family
produces reactive children, which may be manifest as emotional over involvement or emotional
cutoff from the parents, which in turn leads to fusion in new relationships—because people with
limited emotional resources tend to project all their needs onto each other. Because this new
fusion is unstable, it is likely to produce one or more of the following: (1) emotional distance; (2)
physical or emotional dysfunction in one partner; (3) overt conflict; or (4) projection of discord
onto children.

A common case is when a husband who is emotionally reactive to his family keeps his distance
from his wife. This predisposes her to focus on her children. Kept at arm’s length by her
husband, she becomes anxiously attached to the children, usually with greatest intensity toward
one child. This might be the oldest son or daughter, the youngest, or perhaps the child most like
one of the parents. This connection is different from caring; it’s anxious, enmeshed concern. The
more the mother focuses her anxiety on a child, the more that child’s functioning is stunted.

1.8 Societal Emotional Process - Bowen anticipated the contemporary concern about social
influence on how families function. Kerr and Bowen (1988) cite the example of the high crime
rate in communities with highly stressful environments. Bowen recognized sexism and class and
ethnic prejudice as examples of toxic social emotional processes, but he believed that families
with higher levels of differentiation were better able to resist these destructive social influences.

How Therapy Works

Assessment

 Assessment begins with a history of the presenting problem.

 Next comes a history of the nuclear family, including when the parents met, their courtship,
their marriage, and childrearing.
 The next part of the evaluation is devoted to the history of both spouses’ births, sibling
positions, significant facts about their childhoods, and the functioning of their parents. All of
this information is recorded on a genogram covering at least three generations.
 Genograms are schematic diagrams showing family members and their relationships.
Included are ages, dates of marriage, deaths, and geographic locations.

Therapeutic Techniques
The process question- Process questions are designed to slow people down, diminish their
anxiety, and start them thinking— not just about how others are upsetting them but about how
they participate in interpersonal problems. Process questions are designed to explore what’s
going on inside people and between them: “When your boyfriend neglects you, how do you
react?” “What about your wife’s criticism upsets you most?”etc.

Relationship experiment-It is designed to help clients try something different than their usual
emotionally driven responses. Ex: Pursuers are encourage to restrain their pursuit, stop making
demands, decrease pressure for emotional connection and see what happens.

Detriangling- This is probably the central technique in Bowenian therapy. The client is first
helped to recognize both the subtle and the more obvious ways that they are 'triangled' by others,
and the ways in which they attempt to triangle others in their turn. The therapist uses questions to
facilitate the family members' awareness of their roles in family triangles. Simple open ended
tracking questions, using what Herz Brown (1991) terms the four 'Ws' (who, what, when and
where) help clients to become 'detectives' in their own interpersonal systems.

An example would be a client who was struggling to understand her negativity towards her
father. When questioning included her mother's role in these emotions, the client began to see
that her view of her father was influenced by her position in a triangle. As her mother's ally in
this triangle, she viewed her father as the inadequate husband who left her mother feeling needy.

The “I”-Position- Questions that Encourage Differentiation-

The therapist asks questions that assume that the adult client can be responsible for his / her
reactiveness to the other. In response to such questions, family members are encouraged to take
an 'I' position where they speak about how they view the problem, without attacking, or
defending against, another family member (Bowen, 1971a in Bowen, 1978: 252; Goodnow and
Lim, 1997). Clients are taught to make personal statements about their thoughts and feelings in
order to facilitate a greater sense of responsibility in a relationship.

For example, an accusatory statement such as, 'You are so selfish to cause this much worry for
your parents!', is shifted to, 'I am really concerned that this might affect your school grades'. The
parent is encouraged to 'own' their worries, rather than to project their anxieties through
blaming statements.

A Multigenerational Lens - Bowen's multigenerational model goes beyond the view that the
past influences the present, to the view that patterns of relating in the past continue in the present
family system (Herz Brown, 1991). Hence the therapist uses questions to encourage clients to
think about the connection between their present problem and the ways previous generations
have dealt with similar relationship issues. For example, if the onset of a symptom followed a
death in the family, the therapist asks about how grief has been dealt with in previous
generations. Questions seek to uncover family belief systems as well as the way relationships
have shifted in response to loss.

Coaching: Family Therapy with an Individual - Bowen described 'coaching' as 'family

psychotherapy with one family member' (Bowen, 1971). The term 'coaching' describes the work
of the therapist giving input and support for adult clients who are attempting to develop greater
differentiation in their families of origin. The therapist supports their efforts in returning to their
families to observe and learn about these patterns. Clients practice controlling their emotional
reactivity in their family and report their struggles and progress in following sessions. During
family of origin coaching, clients use letters, telephone calls, visits and research about previous
generations to gain a systemic perspective on their family's emotional processes and a sense of
their own inheritance of these patterns. The therapist prepares clients for the anxiety they will
encounter if they shift from their customary roles in their families of origin.

Structural Family Therapy

Salvador Minuchin is the founder of structural family therapy, which has been a leading model
in family therapy since its inception. Structural family therapy focuses upon the person within
the family system, rather than solely on the individual (Colapinto. 1982; Minuchin, 1974).
Structural family therapy recognizes that "man is not an isolate" (Minuchin, 1974, p. 2).
Therefore, within the family system, each member affects the other members. Structural family
therapy is an approach that is founded upon the notion of the "interrelationship of the whole”
(NapolielIo & Sweet, 1992, p. 156). Structural family therapy is also unique in that it focuses on
the present rather than on the past (Colapinto, 1982). The rationale behind this idea is that past
dysfunctions are manifest in current functioning; hence a change in current functioning could
alter embedded dysfunctional behavior (Minuchin, 1974).

Structural family therapy utilizes many concepts to organize and understand the family.
Each of these concepts will be explored in the following section-

Structure: One of the most important tenets of structural family therapy is that every family has
a structure. This phrase refers to how a family organizes itself (Nichols 8 Schwartz, 1998).
Minuchin uses the structure to indicate that families have behavioral patterns, which he describes
as conservative but changeable (Minuchin & Nichols, 1993). A healthy family structure is one in
which there are clear boundaries around the system and its subsystems. Changing a dysfunctional
structure means that therapy is directed towards altering the current structure of the family
(Minuchin, 1974). The goal of therapy is to increase the flexibility of the family structure
(Minuchin & Nichols, 1993).

Subsystems: Minuchin built upon systemic theory by postulating that the family system can be
further divided into subsystems (Lester, 1997). Subsystems are "smaller units of the system as a
whole" (Gladding, 1998a. p. 212) and consist of one or more individuals. Relationships between
subsystems are governed by spoken and unspoken rules (Minuchin et al., 1998). The broad
categories of subsystems that are typical in a family are the parental subsystem, the spousal
subsystem, the parent-child subsystem and the sibling subsystem. In addition to these common
subsystems, it should be noted that each family may also create its own particular subsystems
(Karpel & Strauss, 1983). An example of this could be a family that organized the sibling
subsystems according to gender instead of age.

Boundaries: As pertaining to subsystems, Minuchin suggests that boundaries are the rules which
define "who participates and how much" (1974, p. 53). Gladding (1 W8a) states that boundaries
are "the physical and psychological factors that separate people from one another and organize
them" (p. 21 3). Therefore, boundaries are the invisible barriers that govern the contact that
subsystems have with other subsystems and are necessary for a healthy family structure
(Minuchin & Fishman. 1981). For instance, a door with a lock on it that closes off the parents'
bedroom is one example of a boundary between a couple and sibling subsystem. Accordingly,
boundaries allow the subsystem to perform its functions without interference from other
subsystems (Minuchin, 1 974). In order to function well, boundaries must be clear and not too
rigid (Minuchin, 1974).

Enmeshment: Families with boundaries that are diffuse are described as enmeshed. This is a
state in which the boundaries are too permeable and thus there becomes a sacrificing of
autonomy in order to maintain the greater sense of belonging to the family system (Minuchin.
1974). This system lacks the necessary resources to change under stressful conditions (Minuchin,
1974). An example of an enmeshed family is one that has no doors on the rooms in their home.
This would not allow the family members the privacy they need and would make it difficult to
distinguish where the family ended and the individual began.

Disengagement: Disengagement occurs when families have boundaries that are overly rigid
(Minuchin, 1974). Inflexible boundaries serve to keep people separated from each other. As a
result, family members have difficulty relating to each other in an intimate way and become
disconnected from other family members (Gladding, i998a).

Power: The concept of power refers to the level of influence that each family member has on the
outcome of an activity (Aponte & VanDeusen, 1981). It is the ability to get something done.
Power can Vary according to the setting and it is generated by the way in which family members
react. For example, a father's power may depend on the response from his wife and children,
either reinforcing or negating his power (Aponte 8 VanDeusen, 1981).

Alignment: An alignment refers to the way in which "family members as individuals and as
parts of subsystems relate to each other relative to other family members and subsystem (Nelson
& Utesch, 1990, p. 237). Alignments can include both joining and opposing one member or
subsystem over another (Aponte 8 VanDeusen, 1981). For instance, a mother may disagree with
her husband's method of disciplining their children and consequently may side with the children.

Key Techniques

1. Joining: For the structural family therapist this is a very important concept. as it highlights the
need for the therapist to develop an empathetic relationship with the family in order to modify
the family's current functioning (Minuchin. 1974). It is necessary to establish this bond during
the assessment phase, as joining is a "pre-requisite" to restructuring (Minuchin, 1993). Another
important aspect of joining is looking for strengths in the family. Highlighting the positives will
give the family confidence that they possess useful skills and that they are capable of using these
skills to solve their problems.

The process of joining-

Finding and adopting the language style of the people. With adolescents being idealistic and with
religious people being spiritual, being affectionate with the families that are conformable with
physical closeness (Minuchin, 1993), by accommodation also the therapist "makes personal
adjustments in order to achieve a therapeutic alliance" (Gladding, 1998a).

Boundary making: As stated previously, maintaining clear boundaries around the subsystems is
crucial for healthy family functioning. In a family where the boundaries are too rigid or too
flexible, the therapist would try to create, within the family, boundaries that are autonomous and
yet interdependent enough to allow for the growth of the family members (Jones, 1980).

This can be done in one of two ways, that is, physically or verbally.

With physical boundary making, the therapist may rearrange seating, use hand gestures to
silence other family members or may use his or her own body to block conversations (Minuchin
& Fishman, 1981). Some verbal boundary making includes giving specific instructions to the
family and giving verbal reminders to prohibit interruptions (Minuchin 8 Fishman, 1981 ).

2. Unbalancing: The therapist aims to realign relationships between subsystems. In unbalancing,

the goal is to change relationships within a subsystem. What often keeps families stuck in
stalemate is that members in conflict are balanced in opposition and, as a result, remain frozen in
inaction. In unbalancing, the therapist joins and supports one individual or subsystem. However,
the therapist takes sides to unbalance and realign the system, not as an arbiter of right and wrong.

Enactment: This concept refers to the way in which the family therapist "constructs an
interpersonal scenario in the session in which dysfunctional transactions among family members
are played out" (Minuchin & Fishman, 1981, p. 79). Enactments can illustrate many things about
the family's structure (Nichols & Schwartz, 1998). For example, can the adults discuss an issue
without bringing the children into the argument? Can two family members talk without being
interrupted? Enactments allow the therapist to observe what roles each family member performs
and demonstrate enmeshment or disengagement.

Restructuring: Restructuring simply means changing the structure of the family. Some of the
techniques mentioned above are used to make the family more functional by "altering the
existing hierarchy and interaction patterns so that problems are not maintained (Gladding, 1998).
There are two broad types of structural problems, as pointed out by Aponte and Van Deusen
(1981). The first is system conflict- This is when problems arise due to the competing needs of
the family system or subsystem. An example is a lonely son who relies on his mother to meet his
social needs, but the mother needs to socialize with her spouse. The second is structural
insufficiency- This refers to the problems that arise due to a lack of structural resources to meet
the demands of the system. An illustration is a single father who is trying to raise five children
by himself and is too overwhelmed to meet their needs.

Structural Mapping: Structural assessments take into account both the problem the family
presents and the structural dynamics it displays. And they include all family members. For
example- knowing that the mother and daughter are enmeshed isn’t enough; you also have to
know what role the stepfather plays. If he’s close with his wife but distant from the daughter,
finding mutually enjoyable activities for stepfather and stepdaughter will help increase the girl’s
independence from her mother.

Reframing: It involves examining a situation from a new perspective so that the meaning is
changed. Reframing allows the therapist and the family to focus on the positives and also
challenge the negatives (Minuchin et al., 1998). Reframing highlights the complernentarity of
behaviours (Colapinto, 1991). For example, if a mother and son came to therapy because the
mother is too involved in her son's daily decisions and the therapist said to her that her mothering
illustrates how much she loves her son, she would be able to see that her actions demonstrate her
love. She would also be able to see that the solution may lie in what the therapist calls her
"mothering".

Strategic Family Therapy

Strategic family therapy (SFT) is a short-term family therapy treatment that is often used for
families with children or adolescents who are dealing with behavioral issues. This type of
therapy seeks to identify and change the structural interaction patterns that make up the family
environment. By addressing family behaviors and interactions that contribute to problem
behavior, this approach helps families function better so that kids can overcome issues they are
experiencing.
Brief strategic family therapy (BSFT) is a short-term model that typically consists of 12 to 17
weekly sessions, depending on the severity of the presenting problem. A typical session lasts 60
to 90 minutes.

Techniques of Strategic Family Therapy

1. Joining
2. Tracking and Diagnosing: Once a therapeutic relationship has been established, the therapist
will then work to learn more about the family's behavior patterns and problems. In doing so, they
can identify strengths and maladaptive patterns of interaction that will allow them to develop a
treatment plan.
3. Restructuring:

 Enacting transactional patterns: Having family members act out patterns with each other,
without describing or verbalizing them. not about each other to the therapist or another
family member.
 Manipulating space: Noticing who sits where in sessions and moving them.
 Escalating stress: Increasing the family's experience of stress, to see how they manage it and
to help them practice more effective coping strategies.
 Assigning tasks: Changing and practicing different communication patterns, such as giving
the family homework to change how they are seated at dinner.
 Reframing: Helping the family shift the definition of a problem respectfully and honestly.
 Unbalancing: The therapist briefly joins a subgroup or individual in the family and uses their
authority to change relational dynamics.

4. Directives: The therapist provides direct instructions on what to change and how.

5. Covert change: The therapist provides more subtle suggestions or indirect feedback to
encourage change within the family session (such as praising desired behavior or ignoring non-
desired behavior).

6. Positive Connotation: Similar to reframing, alters view on behavior.

7. Pretend techniques/reversals: The family is encouraged to act “as if”—or to imagine another
set of circumstances to act differently than they normally would.

8. Hypothesizing: The family is encouraged to ask the question "What would happen if...?"

9. Circular questioning: The therapist asks the same question to multiple family members to
illustrate various perspectives of the same issue or problem.

11. Neutrality: Do not align with any specific family member or behavior
What Strategic Family Therapy Can Help With

 Aggressive behaviors
 Conduct problems
 Delinquency
 Noncompliance
 Substance use problems
 Risky sexual behavior
 Violent behavior

The two scientists behind the development of Experiential Family therapy approach is Carl
Whitaker and Virginia Satir. Experiential family therapy is founded on the premise that the root
cause of family problems is emotional suppression. Many parents try to regulate their children’s
actions by controlling their feelings. As a result, children learn to blunt their emotional
experience to avoid criticism.

Experiential Family therapy

An experiential branch of family therapy emerged from the humanistic wing of psychology that
emphasized immediate here-and-now experience. In focusing more on emotional experience than
on the dynamics of interaction, experiential therapists seemed out of step with the rest of family
therapy. Two scientists stand out in the development of experiential family therapy; they are
Carl Whitaker and Virginia Satir.

Experiential therapists describe the family as a place for sharing experience (Satir, 1972).
Functional families are secure enough to encourage a wide range of experiencing; dysfunctional
families are frightened. From an experiential perspective, denial of impulses and suppression of
feeling are the root of family problems (Kaplan & Kaplan, 1978).

How Therapy Works:

Experiential therapists believe that the way to emotional health is to uncover deeper levels of
experiencing, Virginia Satir (1972). They attempt to make three changes in the family system-

 First, each member of the family should be able to report congruently, completely, and
honestly on what he sees and hears, feels, and thinks, about himself and others, in the
presence of others.
 Second, each person should be addressed and related to in terms of his uniqueness, so
that decisions are made in terms of exploration and negotiation rather than in terms of
power.
 Third, differentness must be openly acknowledged and used for growth.
Existential encounter- These encounters must be reciprocal; instead of hiding behind a
professional role, the therapist must be a genuine person who catalyzes change using his or her
personal impact on families.

Therapeutic Techniques- In experiential therapy, according to Walter Kempler (1968), there

are no techniques, only people. Some use structured devices such as family sculpting and
choreography. Virginia Satir, a leading psychologist behind experiential family therapy had a
remarkable ability to communicate. One of Satir’s hallmarks was the use of touch. She often
began by making physical contact with children, as evidenced in her case “Of Rocks and
Flowers.”

Experiential therapists use a number of expressive techniques-

 Family puppet interviews

 Family art therapy
 Conjoint family drawings
 Gestalt therapy techniques

Family sculpting- One well-known experiential technique is family sculpting. Developed by

Duhl, Kantor, and Duhl (1973), family sculpting consists of placing family members in positions
and postures that represent their relationships and interactions.Anyaspect of family functioning
can be sculpted (e.g. closeness, power or anger). Family sculpting requires a sculptor, whose
view of the family is revealed
in the sculpture; a monitor, namely the therapist, who guides the sculptor and the others; and the
actors, who portray the sculptor’s family system. Walrond-Skinner (1976) suggested sculpting
for families with young children in therapy, who may find it easier to express themselves non-
verbally. Sculpting can be used diagnostically, a substitute for asking a family for a verbal
description of their problems or desired changes, and to help family members get in touch with
their feelings. Sculpting can be used to overcome families’ resistance to therapy or a creative
strategy when you feel ‘stuck’.

Family art therapy or family drawing- In this families are instructed to produce a series of
drawings, including a “joint family scribble,” in which each person makes a quick scribble and
then the whole family incorporates the scribble into a unified picture. In this procedure families
are told to “Draw a picture as you see yourselves as a family.” The resulting portraits may
disclose perceptions that haven’t previously been discussed or may stimulate the person drawing
the picture to realize something that he or she had never thought of before.

Animal attribution story-telling technique- It requires family members to choose an animal to

represent each member of the family and then tell a story about the animals.

Family puppet interviews- Irwin and Malloy (1975) ask one of the family members to make up
a story using puppets. This technique, originally used in play therapy, is designed to highlight
conflicts and alliances. Puppets also provide a safe avenue for symbolic communication. For
example, a child who has used a specific puppet to symbolize his anger (e.g., a dinosaur) may
simply reach for the dinosaur whenever he feels threatened.

Role-playing- Role playing is another action technique that can be useful when verbal
approaches prove ineffective. It can be especially valuable in families who intellectualize their
problems. Having them act out scenes or events from their lives can facilitate change. For
example, a family might be asked to act out what happens when father returns home from work
or at bedtime, if they report difficulties during these times. If family members are hesitant, the
therapist may start with a simple, non-threatening scene, but if rapport has been well established,
obtaining agreement is usually not difficult.

Family psychodrama
Oxford and Wiener (2003) describe the use of dramatic techniques with a family hit hard by
multiple losses. After setting the stage for this intervention and framing the problem in an
externalized way (see Chapter 11), The therapist asked each family member to enact their
experience of sadness, and then to speak to sadness about how sadness has influenced their lives.
In the next session, they were asked to place themselves along a continuum representing the
amount of control they thought sadness had over the family and how much they would like to
have.

Gestalt empty chair technique- When someone who isn’t present is mentioned this technique is
used. If a child talks about her grandfather, she might be asked to speak to a chair, which is used
to personify grandfather.

Family albums- Hesse and Karakurt (2012) described the use of a family album to help children
better understand their parents’ divorce, deal with their feelings and accept its finality. The
therapist introduces the idea of a family photo album and invites the family to draw their own
family album to tell about their family. The therapist can provide a worksheet or template with
blank ‘frames’ as would be seen in a photo album, along with drawing materials. Under each
frame is a description of the picture that the child will be drawing in the box. The therapist reads
the description to the child, who draws his or her picture in the box. Possible descriptions include
‘Happy Times with my Family’, ‘Sad Times with my Family’,

Psychoanalytic Family Therapy

At the heart of human nature are the drives—libidinal and aggressive. Mental conflict arises
when children learn, and miss learn, that expressing these impulses directly will lead to
punishment. The resulting conflict is signaled by unpleasant affect: Anxiety is a unpleasant
emotion associated with the idea (often unconscious) that one will be punished for acting on a
particular wish—for example, the anger you’re tempted to express might make your partner stop
loving you.
The balance of conflict can be shifted in one of two ways: by strengthening the defenses against
one’s impulses or by relaxing defenses to permit some gratification.

Self Psychology- The essence of self psychology (Kohut, 1971, 1977) is that every human being
longs to be appreciated. If our parents are enthusiastically responsive and appreciative, we
internalize this acceptance in the form of a self-confident personality. But to the extent that our
parents are unresponsive or rejecting, then our craving for appreciation is retained in an archaic
manner. The child lucky enough to grow up with appreciative parents will be secure, able to
stand alone as a center of initiative, and able to love. The unhappy child, cheated out of loving
affirmation, will move through life forever craving the attention he or she was denied. This is the
root of narcissism.

Therapeutic Techniques- There are four basic techniques: listening, empathy,

interpretations, and analytic neutrality.

 Sessions begin with the therapist inviting family members to discuss current concerns,
thoughts, and feelings. In subsequent meetings, the therapist might begin by saying nothing
or perhaps “Where would you like to begin today?” The therapist then leans back and lets the
family talk.
 When initial associations and spontaneous interactions dry up, the therapist probes gently,
eliciting history, people’s thoughts and feelings, and their ideas about family members’
perspectives. This technique underscores the analytic therapist’s interest in assumptions and
projections. Particular interest is paid to childhood memories.
 After the roots of current family conflicts have been uncovered, interpretations are made
about how family members continue to reenact past and often distorted images from
childhood. The data for such interpretations come from transference reactions to the therapist
or to other family members, as well as from childhood memories.
 Analytic neutrality- To establish an analytic atmosphere, it’s essential to concentrate on
understanding without worrying about solving problems. The analytic therapist resists the
temptation to reassure, advise, or confront families in favor of a sustained but silent
immersion in their experience. When analytic therapists do intervene, they express empathy
in order to help family members open up, and they make interpretations to clarify hidden
aspects of experience. Most psychoanalytic family therapy is done with couples. It is done by
analyzing : (1) internal experience, (2) the history of that experience, (3) how the partner
triggers that experience, and, finally, (4) how the context of the session and the therapist’s
input might contribute to what’s going on between the partners.
 Cognitive Behavioral Family Therapy
When they first began working with families, behavior therapists applied learning theory to train
parents in behavior modification and teach communication skills to couples. These approaches
were effective with simple problems and well-motivated individuals. The early principles of
behavior therapy were developed by two key figures: Joseph Wolpe and B. F. Skinner.

Cognitive-behavior therapy refers to those approaches inspired by the work of Albert Ellis
(1962) and Aaron Beck (1976) that emphasize the need for attitude change to promote and
maintain behavior modification. According to the cognitive mediation model (Beck, 1976),
actions are mediated by specific cognitions.

Rational-emotive therapists help family members see how illogical beliefs serve as the
foundation for their emotional distress. According to the A-B-C theory, family members blame
their problems on certain events in the family (A) and are taught to look for irrational beliefs (B),
which are then challenged (C). The therapist’s role is to teach families how emotional problems
are caused by unrealistic beliefs and that, by revising these self-defeating ideas, they may
improve the quality of family life (Ellis, 1978). .

Theory of social exchange- According to Thibaut and Kelley (1959), people strive to maximize
rewards and minimize costs in relationships. In a successful relationship partners work to
maximize mutual rewards. In unsuccessful relationships the partners are too busy protecting
themselves from getting hurt to consider how to make each other happy.

Development of Behavior Disorders- Parents commonly respond to misbehavior by scolding

and lecturing. These responses may seem like punishment, but they may in fact be reinforcing,
because attention—even from a critical parent—is a powerful social reinforcer (Skinner, 1953).
The truth of this is reflected in the axiom, “Ignore it, and it will go away.” The problem is, most
parents have trouble ignoring misbehavior.

The following is a typical example: A mother, father, and small child are riding in the car. The
father speeds up to make it through a yellow light. His wife insists that he slow down and drive
more carefully. The father, who hates being told what to do, gets angry and starts driving faster.
Now his wife yells at him to slow down. The argument escalates until the child, crying, says,
“Don’t fight, Mommy and Daddy!” Mother turns to the child and says, “It’s okay, honey. Don’t
cry.” Father feels guilty and begins to slow down. Consequently, the child learns at a young age
the power and control she has in the family.

The use of aversive control—crying, nagging, withdrawing—is a major determinant of marital

unhappiness (Stuart, 1975). Spouses tend to reciprocate their partners’ use of aversive behavior,
and a vicious cycle develops (Patterson & Reid, 1970).
According to cognitive-behaviorists, the schemas that plague relationships are learned in the
process of growing up. The following are typical cognitive distortions:

1. Arbitrary inference: Conclusions are drawn in the absence of supporting evidence; for
example, a man whose wife arrives home late from work concludes, “She must be having an
affair,” or parents whose child comes home late assume, “He must be up to no good.

2. Selective abstraction: Certain details are highlighted while other important information is
ignored; for example, a woman whose husband fails to answer her greeting first thing in the
morning concludes, “He must be angry at me again,”.

3. Overgeneralization: Isolated incidents are taken as general patterns; for example, after being
turned down for a date, a young man decides that “Women don’t like me; I’ll never get a date”.

4. Magnification and minimization: The significance of events is unrealistically magnified or

diminished; for example, a husband considers the two times in one month he shops for groceries
as fulfilling his share of the household duties, while his wife thinks, “He never does anything.”

5. Personalization: Events are arbitrarily interpreted in reference to oneself; for example, a

teenager wants to spend more time with his friends, so his father assumes that his son doesn’t
enjoy his company.

6. Dichotomous thinking: Experiences are interpreted as all good or all bad; for example, Jack
and Diane have some good times and some bad times, but he remembers only the good times,
while she remembers only the bad times.

7. Labeling and mislabeling: Behavior is attributed to undesirable personality traits; for

example, a woman who avoids talking with her mother about her career because her mother
always criticizes is considered “withholding.”

8. Mind reading: This is the magical gift of knowing what other people are thinking without the
aid of verbal communication; for example, a husband doesn’t ask his wife what she wants
because he “knows what’s going on in her mind”.

The Cognitive-Behavioral Approach to Family Therapy

Dattilio (2005) suggests that individuals maintain two sets of schemas about family life: (1)
schemas related to the parents’ experiences growing up in their own families, and (2) schemas
related to families in general, or personal theories of family life. Both types of schemas influence
how individuals react in the family setting. For example, a woman raised with the belief that
family members should do things together may feel threatened if her husband wants to do certain
things on his own.

Therapeutic Techniques-
A major goal of the cognitive approach is to help family members learn to identify automatic
thoughts that flash through their minds. The importance of identifying such thoughts (She’s
crying—she must be mad at me.) is that they often reflect underlying schemas (Women usually
hold men responsible for their unhappiness.) which may be inaccurate.

To improve their skill in identifying automatic thoughts, clients are encouraged to keep a diary
and jot down situations that provoke automatic thoughts and the resulting emotional responses.
The therapist’s role then is to ask a series of questions about these assumptions, rather than to
challenge them directly.

In addressing the schemas in this family, the therapist followed a series of eight steps to
uncover and reexamine them:

 Identify family schemas and highlight those areas of conflict that are fueled by them
(e.g., “We have to walk on eggshells with mom. If we show any signs of weakness, she
flips out.”).
 Trace the origin of family schemas and how they evolved to become an ingrained
mechanism in the family process. This is done by exploring the parents’ backgrounds.
Similarities and differences between the parents’ upbringings should be highlighted to
help them understand areas of agreement and conflict.
 Point out the need for change, indicating how the restructuring of schemas may facilitate
more adaptive and harmonious family interaction.
 Elicit acknowledgment of the need to change or modify existing dysfunctional schemas.
This step paves the way for collaborative efforts to change. When family members have
different goals, the therapist’s job is to help them find common ground.
 Assess the family’s ability to make changes, and plan strategies for facilitating them.
 Implement change. The therapist encouraged family members to consider modifying
some of their beliefs in a collaborative process of brainstorming ideas and weighing their
implications.
 Enact new behaviors. This step involves trying out changes and seeing how they work.
Family members were each asked to select an alternative behavior consistent with the
modified schema and to see how acting on it affects the family.
 Solidify changes. This step involves establishing the new schema and its associated
behavior as a permanent pattern in the family.
 Imagery and role-playing may be used to help family members remember past incidents
that helped them form assumptions. On occasion, family members are coached to switch
places in role plays to increase their empathy for each other’s feelings (Epstein &
Baucom, 2002).
 Among the homework assignments commonly used in this approach are practicing
communication skills—for example, deliberately engaging in an argument but without
attacking or using condescending language.
  Frank Dattilio (1999) introduced the “pad-and pencil” technique to help family
members overcome the annoying habit of interrupting each other. Family members are
given a pad and pencil and asked to record the automatic thoughts that go through their
minds when someone else in the family is talking. Once the first person has finished
speaking, the therapist asks the other person talk about the thoughts and feelings he or she
was having while listening.
 Therapists provide guidelines and coaching to help clients learn to express themselves in
ways that won’t lead to recrimination. This may involve using downward arrow
questioning to help family members learn to differentiate and articulate their feelings and
the cognitions underlying them, coaching clients to notice internal cues to their emotional
state, having them learn to express their emotions in understandable terms, refocusing
attention on emotional topics when clients attempt to change the subject.
 Contacting for treatment- All the family members and child-protection workers if
involved, must be present.

SOLUTION-FOCUSED BRIEF
FAMILY THERAPY
Solution-focused brief therapy (SFBT) evolved out of systemic and brief family therapy at the Brief
Family Therapy Center in Milwaukee during the late 1970s and early 1980s by two social workers, Steve
de Shazer and Insoo Kim Berg.

o The Co-construction Process- Coconstruction is a collaborative communication process in

which the speaker and the listener work together to negotiate meanings, and the information
produced together in turn acts to shift meanings and social interactions (Bavelas et al., 2013).
The process involves the therapist following the client’s words in a conversation, grounding
the meaning of those words between therapist and client, and directing a conversation with a
client in a way that will help him or her envision self-determined goals and solutions (Lee et
al., 2007).
o Positive Emotion and Expectancies for Change- Purposefully increasing positive
expectancies and positive emotions such as hope and optimism has frequently been discussed
as important to the change process in SFBT.
o One of the SFBT process suggested by Kiser et al.(1993) for increasing positive emotions
involves translating emotional states into more concrete behavioral states, which is necessary
for the client to view his or her situation in a new and positive way.

SOLUTION-FOCUSED BRIEFTHERAPY QUESTIONS-

Questions That Build Client Competencies- Questions that build client competencies help the
Client builds positive emotional responses. By asking the client to define, identify, or reflect on
what went well.
 What has been going well in your life?
 How would you know if our talk would make a big difference?
 What accomplishments are you most proud of?
 How did you know that was the right thing to do?
 What I am hearing is that you are able to . . . How does it feel to know what your strengths
are?
 What I see about you is that you are good at . . . How does it feel to hear that from me?

Exception Questions- Exception questions are those that allow practitioners and clients to
explore points in the client’s life in which an identified problem could have occurred, but did not.

 Can you tell me about a time when this problem did not occur?
 What was different then?
 What’s been better?
 What has changed?
 What has been your best day?
 What are you good at?
 Tell me about a time when you avoided getting in trouble. How did you do that?

Relationship Questions- Relationship questions are those that allow clients to reflect on how
others in their life perceive them and to notice different behaviors and social interactions that
may lead to different responses.

Miracle Question- The miracle question provides clients with an opportunity to reconstruct their
story by identifying a preferred future without perceived problems (Berg & De Jong, 1996).

Goal-Setting Questions- In order to set an appropriate goal, therapists need to have

conversations with clients about how they want their lives to be different. Questions include,
 “What has to happen for it to be worth your time to come here today?,”
 “Suppose after we talk today that your life would be different—what would have to happen?”
 “What do you want to happen instead?”

Scaling Questions- Scaling questions provide clients with the opportunity to examine or
evaluate progress towards identified goals, and also serve as a method for envisioning the next
steps needed in building a solution.

MULTIPLE FAMILY
GROUP THERAPY
In 1964, Peter Laqueur, a Dutch psychiatrist transported to the United States and working in a
state hospital setting, reported about his experiences bringing families together with their
hospitalized chronic schizophrenic members. The goal was to directly involve families in patient
management strategies, a radical idea at the time. Laqueur called this new type of clinical
intervention multiple family therapy.

Some of these MFGs follow highly structured protocols; others are designed as open-ended
groups in which families can come and go based on their needs. Some are designed as 1-day
workshops, some are delimited six to eight session experiences for a group of families who go
through the experience together, and yet others are open-ended groups that may extend over
months or even more than a year.

There are 3 Core Features of Multiple Family Group Therapy-

1) A Community of Families With Shared Experiences- Families report over and over again
that one of their most distressing experiences in dealing with the challenges of chronic
psychiatric or medical illness is a pervasive sense of isolation. This isolation is often expressed
as a belief that friends, extended family members, and work colleagues simply cannot understand
what their lives are like and that they must therefore fend for themselves. By bringing together a
group of families dealing with similar issues, this sense of isolation is undercut and the
experiences families are having and their reactions to these experiences are normalized.
2) Establishing a Non-blaming, Nonjudgmental Atmosphere- MFG protocols have directly
challenged and countered earlier ideas that family behavior might play a role in exacerbating or
prolonging negative outcomes for patients with major psychiatric and/or medical illnesses.
3) Emphasizing Collaborative Problem-Solving- The structural richness of the MFG model
has allowed clinicians to design features and exercises that allow participants to have access to
the multiple perspectives introduced by group members (a) within each family, (b) between
families, and (c) between families and professionals.

MULTISYSTEMIC FAMILY THERAPY

Multisystemic Family Therapy (Henggeler, et al., 2009) is a family- and community-based

treatment for youth with serious clinical problems and at high risk for out-of-home placement,
developed in the late 1970s.
MST contends that most serious clinical problems affecting youth and families, such as juvenile
offending, child maltreatment, or serious mental health conditions, are caused by a complex set
of risk factors operating at multiple systemic levels. In the case of juvenile offending, cross-
sectional and longitudinal research has implicated a consistent set of risk factors across multiple
systems, including individual (e.g., cognitive biases about aggression, low social skills), family
(e.g., low parental supervision, inconsistent family discipline), peer (e.g., association with
deviant peers), school (e.g., low academic achievement), and neighborhood (e.g., high drug
availability) systems.

Multisystemic Therapy Treatment Delivery-

 MST uses a team-based approach to service delivery for juvenile offenders, by a team
consisting of two to four full-time master’s level therapists and a part-time master’s or
doctoral level supervisor, with administrative support.
 Members of an MST team usually work for private service provider organizations contracted
by public juvenile justice, child welfare, or mental health authorities.
 Therapists typically carry caseloads of four to six families.
 Treatment duration is relatively brief, ranging from 3 to 6 months and often involves 60 to
100 hours of direct contact with the family and other members of the ecology.
 There is a strong emphasis on the delivery of MST services in home- and community-based
settings.
 A key treatment principle is that all aspects of MST must be strength based. Therapists look
for potential strengths within the contexts of the child (e.g., hobbies and interests, academic
skills), parent (e.g., employed, motivated), family (e.g., problem-solving ability, affective
bonds), peers (e.g., prosocial activities, achievement orientation), school (e.g., management
practices, afterschool activities), and the neighborhood/community (e.g., concerned and
involved neighbors, Boys and Girls clubs).

Family Therapy can be used in special problems and issues :

1. Schizophrenia-Spectrum Disorders
2. Major Depressive Disorder and Bipolar Disorders
3. Eating Disorders
4. With minority families
5. Problems with the one parent family
6. Treating step-families
7. Sex therapy for couples
8. Arbitration of family dispute
9. Issues of divorce
10. Child Abuse and neglect

INDICATIONS

1. The problem manifests in explicit family terms and the therapist readily notes the families
dysfunctions. For example- a marital conflict dominates, with repercussion for the children;
or tension between parents and an adolescent child dislocates family life with everyone
ensured in the conflict. In these situations family is the target of intervention.
2. The family has experienced a disruptive life event which has lead to its dysfunction. These
events are either predictable or accidental and include, suicidal death, functional
embarrassment, diagnosis of a serious physical illness, and the unexpected departure of a
child from home.
3. Continuing, demanding circumstances in a family are of such a magnitude as to lead to
ineffective adjustment. The family’s resources may be stretched to the hilt; external sources
of support may be scanty or unavailable. Typical situations are chronic physical illness.
4. An identified patient may have become symptomatic in the context of a dysfunctional family;
symptoms are in fact an expression of that dysfunction. Depression in a mother, an eating
problem in daughter, alcohol misuse in a father, through family assessment ,are adjudged to
reflect underlying family difficulties.
5. A family member is diagnosed with a conventional condition such as schizophrenia or
depression; the complications are the adverse reverberations within the family stemming
from the diagnosis. For example- The son with schizophrenia taxes his parents in ways that
exceed their ‘problem solving’ capacity; an agoraphobic woman insists on the constant
company of her husband in activities of daily living etc. In these circumstances members
begin to respond maladaptively to the diagnosed relatives, which paves the way for a
deterioration of the patients condition.
6. Thoroughly disorganized families, buffeted by man problems, are viewed as the principle
target of help. Thisis apposite, even though, for instance, one member abuse drugs, another is
prone to violence and a third manifests antisocial behavior. Regarding the family as the core
dysfunctional unit is the rational rather than a focus on each members individual problems.

Contraindications for family therapy:

1. If key family members are unavailable for geographical or other reasons or are completely
unmotivated to become involved in treatment, family therapy may have to be ruled out.
2. Another factor is the availability of a suitably trained and experienced therapist. Family
therapy is a complex and often difficult undertaking, and it is important that the skills of the
therapist be matched to the needs of the family.
3. Family therapy may be contraindicated because the family presents too late in the course of
the disorder. The outlook may be too poor to justify the necessary expenditure of time and
 money, though this is very much a value judgment and the question of whether a family
wishes to spend its money on family therapy is perhaps its decision, rather than the
therapist’s.
4. Shared motivation for changes is lacking. One or more member may wish to participate, but
their chances of benefiting from a family approach are likely to be less than if commeting
themselves to individual therapy.
5. It may be dangerous to attempt family therapy when ‘the emotional equilibrium is so
precariously maintained that attempts to change the relationship system may precipitate a
severe decompensation on the part of one or more family members’.
6. It is certainly the case that many families maintain themselves in a precarious and stressful
adjustment. In some cases an alteration in the family situation could increase the stress faced
by one or more individuals. This in turn could lead to a worsening of their condition with
perhaps depression or even suicide.
7. The level of family disturbance is so severe or long-standing, that a family approach seems
futile, according to the best possible clinical judgment. For example- a family that has fought
bitterly and incessantly for years is unlikely to engage in the constructive purpose of
exploring the patterns of functioning.
8. The patient is too incapacitated to withstand the demands of family therapy. Someone in the
midst of a psychotic episode or buffeted by severe melancholia is too effected by the illness
to engage in family therapy.
9. Some therapists consider that family therapy may be contraindicated in the presence of
depression or severe emotional deprivation in one or more members. Walrond-Skinner
suggested that the combination of individual treatment for the members with these symptoms
may in such cases be combined with sessions for the whole family.
10. Finally, Walrond-Skinner (1976) advocated caution when the family is referred by an agency
such as a court or school. In such cases there may be a hidden agenda, for example, the
family’s desire to avoid a more severe sentence or to prevent a child from being expelled
from a school, rather than a real wish to change. If the family is deeply involved with other
agencies, the therapist’s relationship with these agencies and their role in the treatment and
the disclosure of any information arising from it should be clearly defined before therapy is
begun. Sometimes it is found that it is the family/agency system that should be the focus of
treatment.
 Ethics in Family Therapy
To assist us in this endeavour, the American Association of Marriage and Family Therapy has
developed a Code of Ethics, the latest revision of which was promulgated on 1st July 2012. This
is an important document to which all marriage and family therapists should pay heed. It can be
obtained from:
AAMFT Ethics Committee
112 South Alfred Street
Alexandria, VA 22314
USA
It is also available online ([email protected]).

The ethical issues by which family therapists should abide are set out in the
code as eight ‘principles’. These are-

Principle I – Responsibility to Clients.

Principle II – Confidentiality.
Principle III – Professional Competence and Integrity.
Principle IV – Responsibility to Students and Supervisees.
Principle V – Responsibility to Research Participants.
Principle VI – Responsibility to the Profession.
Principle VII – Financial Arrangements.
Principle VIII – Advertising.
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8_14

Epstein, Bishop and colleagues developed the Family Assessment Device

(FAD; Epstein, Baldwin,&Bishop, 1983), a standardized self-report instrument;
the McMaster Clinical Rating Scale (MCRS; Miller, Kabacoff, Bishop,
Epstein, & Keitner, 1994), which is completed by the assessor after a family
interview; and the McMaster Structured Interview of Family Functioning
(McSIFF; Bishop, Epstein, Keitner, Miller, & Zlotnick, 1980). This combination
of assessment modalities provides a comprehensive system of family
evaluation. The McMaster model gave rise to Problem centered systems
therapy of the family (Epstein & Bishop, 1981), an integrative approach
to family therapy that contains the major stages of assessment, contracting,
treatment and closure, each containing a series of sub-steps.
Skinner, Steinhauer, and Santa-Barbara (1995) developed the Family
assessment measure, third edition (FAM-III). Family members aged 12
and older complete the Dyadic Assessment Scale, reporting on the relationship
between oneself and each other family member; a Self-Rating Scale,
describing one’s perceived connection with the family; and the General
Scale, assessing family functioning in general.