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7
Family Therapy
Systemic Approaches to Practice
FROMA WALSH
FAMILY
SYSTEMS
THEORY AND PRACTICE
Family systems theory has become an essential
frame work to understand human functioning and
dysfunc tion in context. Over recent decades, family
therapy theory and practice 'have become more
responsive to the growing diversity and complexity
of families in our changing world. This chapter first
summarizes core concepts in a family systems
orientation, with a focus on the interaction of
biopsychosocialspiritual
influences,
a
multigenerational family life cycle per spective, and
a conceptual model of family stress and resilience.
Family assessment guidelines are offered, including
a framework identifying key processes in family
functioning and resilienceto inform strengths
oriented family intervention. An overview is provided
of foundational models of family therapy and more
recent collaborative, communitybased approaches
and evidencebasedmodels. Current practices include
varied intervention formats with individuals, couples,
and families, from consultation and brief therapy to
multisystemic approaches, multifamily groups, and
more intensive family therapy.
Family
154
Therapy
Biopsychosocial-Spiritual
Orientation
MULTIGENERATIONAL
FAMILY LIFE CYCLE PERSPECTIVE
In a systemic model, individual and family develop
ments are seen to coevolve over the life course and
across the generations
(McGoldrick et al., 2010).
Relationships grow and change, boundaries shift,
roles are redefined, and new members and losses
require adaptation. Each developmental phase poses
ASSESSMENT OF
FAMILY FUNCTIONING
Mapping the Family System
In clinical practice, a broad conception of family is
needed to encompass the wide range of family struc
tures, relationship options, and cultural diversity in
Table 7.1
Belief Systems
Making Meaning of Adversity
View resilience as relationally based
Normalize and contextualize distress
Sense of coherence: view crisis as a meaningful, comprehensible, and manageable challenge
Appraise adverse situation, options, and future expectations
Positive Outlook
Hope, optimistic bias; confidence in overcoming barriers .
Courage/encouragement; affirm strengths and potential
Active initiative and perseverance
Master the possible; accept what can't be changed
Transcendence and Spirituality
Larger values and purpose
Spirituality: faith, rituals and practices, and congregational support
Inspiration: new possibilities, dreams; creative expression; social action
Transformation: learning, change, and growth from adversity
Organizational Patterns
Flexibility
Adapt to meet new challenges, rebound, and reorganize
Regain stability, continuity, and dependability through disruption
Strong authoritative leadership: nurture, guide, and protect
Varied family forms: cooperative parenting/caregiving teams
Couple/coparent relationship: equal partners
Connectedness
Mutual support, collaboration, and commitment
Respect individual needs, differences, and boundaries
Seek reconnection and reconciliation of troubled relationships
Social and economic resources
Mobilize kin and social and community networks; recruit mentors
Financial security; workfamily balance; institutional supports
Communication/Problem Solving
Clarity
Clear and consistent messages (words and actions)
Clarify ambiguous information; truth seeking/truth speaking
Open Emotional Expression
Share range of feelings (joy and pain, hopes and fears)
Mutual empathy; tolerance for differences
Responsibility for own feelings and behavior; avoid blaming
Pleasurable interactions, respite; humor
Collaborative Problem Solving
Creative brainstorming; resourcefulness
Shared decision making; negotiation; resolve/repair conflicts
Focus on goals, concrete steps: build on success;learn from failure
Proactive stance: prevent crises; prepare for future challenges
divorced jointcustody
family, a stepfamily, and a
threegenerational household must organize family
roles and relationship patterns in varied ways to fit
their circumstances.
Adaptability-a counterbalance of flexibility
and stability-is required for effective family func
tioning and resilience (Beavers & Hampson, 2003;
Olson & Gorall, 2003). Families need strong lead
ership with predictable and consistent rules, roles,
and patterns of interaction. Families must also
adapt to changing conditions or new developmen
tal priorities. Without this flexible structure, fami
lies at dysfunctional extremes tend to be either
overly rigid and autocratic or chaotically disorga
nized, unstable, and leaderless. In times of crisis,
such as a medical emergency, or disruptive transi
tions, such as a changing household, flexibility
must be counterbalanced by efforts to restabilize,
reorganize, and reestablish patterns in daily living.
Significant losses may require major adaptational
shifts to ensure continuity of family life. For
instance, when a breadwinner father is laid off or
becomes disabled, family roles change as the
mother becomes the sole earner, and he assumes
most homemaking/childrearing responsibilities.
Connectedness, or cohesion, is vital for family
functioning and resilience. To function well, families
need to balance closeness with respect for separate
ness and individual
differences. Extremes of
enmeshment or disengagement tend to be dysfunc
tional. However, with varying cultural norms, per
sonal preferences,
and situational
demands,
clinicians must be cautious not to presume that a
highly connected couple or family pattern is dys
functionally enmeshed. Many cultures value high
cohesion and prioritize the needs of the family over
individual preferences (Falicov, 1998).
Role relations often must be renegotiated in fam
ilies. Increasingly, couples are striving for equal
partnership in marriage and family life, with both
spouses in the workplace and sharing childrearing
and household responsibilities. Still, more tradi
tional patriarchal values and role divisions are often
upheld by older generations, recent immigrants, and
adherents of fundamentalist
religions. Research
Communication Processes
Communication
processes facilitate all family
functioning. Family therapists attend to both con
tent and relational aspects of verbal and nonverbal
messages. It is important for family members to
communicate
openly about practical, emotional,
and relational issues. Clinicians should be mindful
of varied cultural norms regarding directness and
expressivity of opinions and feelings.
Clarity. Clear and congruent messages conveyed
in words and actions are important. In ambiguous
situations, such as an unclear medical prognosis or
the threat of divorce, anxiety is heightened. When
communication
is blocked, children sense anxiety,
imagine the worst, and commonly express fears
through somatic or behavioral symptoms.
Open emotional expression. A climate of mutual
trust encourages open expression of a range of feel
ings and empathic responses, with respect for differ
ences. Troubled families tend to perpetuate mistrust,
blaming, and scapegoating. Highly reactive, destruc
tive cycles of conflict can escalate into violence.
Cascading effects of criticism, stonewalling, con
tempt, and mutual withdrawal contribute to despair
and divorce (Gattman & Levenson, 2002). It is
important to address with sensitivity areas of conflict
and toxic subjects where communication is blocked
or distorted, as well as constraints of genderbased
assumptions. Expectations that men should be tough
for
families
to thrive
MAJOR APPROACHES
TO FAMILY THERAPY
Table 7.2 presents an outline of major models
of family therapy, their views of functioning/
dysfunction, change processes, and therapeutic
goals. Reflecting the mental health field's focus on
psychopathology, foundational family therapy
models tended to focus on changing dysfunctional
family patterns in the maintenance of individual
symptoms. Over the past three decades, the field of
family therapy has expanded the theory and appli
cation of family systems interventions and has
refocused attention from family deficits to family
strengths. (For a fuller description of models, see
Goldenberg
& Goldenberg, 2004; Nichols &
Schwartz, 2008.) The approaches differ in focus on
particular aspects of functioning and wellbeing:
multigenerational
patterns and relational dynam
ics, structural patterns, communication,
problem
solving, and language and meaning systems. Despite
many differences, family systems approaches attend
to ongoing transactional processes and relational
connections.
IntergenerationalApproaches
Early in the field of family therapy, growth
oriented intergenerational approaches to family ther
apy sought to bridge psychodynamic, object relations,
and family systems theories. In psychodynamically
oriented approaches, therapists attend to the web of
dynamic processes in the family network of relation
ships. In theory, a shared projection process, based
on complementarity of needs, influences mate choice
as well as couple and parentchild relationship pat
terns. Unresolved conflict or loss interferes with real
istic appraisal and response to other family members.
Current life situations are interpreted in light of the
parents' inner object world and role models, con
tributing to distortion, scapegoating, and irrational
role assignment. Symptoms can result from attempts
by spouses/parents to reenact, externalize, or master
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163
164
Family
165 Therapy
Experiential Approaches
Experiential approaches to family therapy were
developed by two leading pioneers, Virginia Satir
(1972), who blended a communication approach with
a humanistic frame of reference, and Carl Whitaker
(1992), who practiced an idiosyncratic style of inter
vention. Experiential approaches are highly intuitive
and relatively atheoretical. As the natural consequence
of life experience, old pains can be aroused by current
interaction, regardless of awareness or intent. The aim
of these growthoriented approaches is fuller aware
ness and appreciation of oneself in relation to others,
achieved through an intense, affective experience with
open communication of feelings and differences. In a
phenomenological approach to assessment and inter
vention focused on the immediate experience, the ther
apist elicits important information in transactions. The
approach encourages exploration, experimentation,
and spontaneity of members' responses to each other.
Experiential exercises, such as family sculpting and role
play, are used to catalyze this process. The therapist
is facilitative, following and reflecting family processes
and stimulating nondefensive, genuine relating.
PROBLEM-SOLVING APPROACHES
Structural Model
Structural
family
therapy,
developed
by
Minuchin (1974) and colleagues at the Philadelphia
Child Guidance Center, has emphasized the impor
tance of family organization for the functioning of
the family unit and the wellbeing of its members.
approaches,
toward practices that support chil
dren's ongoing connections and knit together bio
logical and foster or kinship care family systems
(Minuchin, Colapinto, & Minuchin, 2006).
Strategic/Systemic Approaches
Early strategic and systemic approaches to family
therapy were developed by the MRI (Mental
Research Institute) group in Palo Alto (Weakland,
Fisch, Watzlawick,
& Bodin, 1974), by Haley
(1976) and Madanes (1981), and by the Milan team
(Boscolo, Cecchin, Hoffman, & Penn, 1987). These
models portray presenting problems as both a symp
tom of and a response to current stresses, a commu
nicative act within a repetitive
sequence of
interactions. According to this perspective, therapy
focuses on how a family has attempted to solve its
problems, because a misguided attempt may make
matters worse; and most families do what they do
because they believe it is the best way to approach a
problem or the only way they know. The therapeu
tic task is to interrupt ways of handling the problem
that are not working. The therapist initiates change
to get a family "unstuck" from unworkable interac
tional patterns maintaining
symptoms. Therapy
focuses on altering the feedback loop that maintains
symptomatic
behavior. Early strategic approaches
assumed that symptoms serve a function in the fam
ily and that change depends more on indirect means
of influence than on insight or simply improving
communication. The therapist's stance is remote, yet
active and pragmatic, planning and carrying out a
strategy to achieve specific objectives.
Several techniques are widely used. Relabeling,
reframing, and positive connotation involve strate
gic redefinition of a problem situation to cast it in
a new light. They are commonly used to rede
fine what has been viewed negatively as a well
intentioned attempt to adapt or to protect other
family members. These techniques can be useful in
shifting a family's rigid view or response, altering
an unproductive blaming process, or overcoming
barriers to change. In the reformulation of a prob
lem, new solutions can become more apparent.
Directives are carefully designed behavioral tasks
acknowledgment,
and
tion
on coercive
and
reliance
maladaptive
behavior
Intervention
crete,
more
members
effective
by changing
behavior
learn
tiation
each
in varied
situations.
therapist
assumes
Numerous
effectiveness
conduct
model
(Sexton
one another
consequences
by attention
Within
of
Individuals
and
instead
solving,
guides
way to learn
with
approval
behavior
in con
therapist
of reinforcement).
acknowl
of reinforcing
or punishment.
adaptabil ity
a positive
alliance, the
a role as educator,
model, and
skills in nego
increasing
of this approach
disorders,
ily therapy
colleagues
The
builds communication
and problem
facilitator.
distress.
specified
of dealing
other
behavior
The therapist
exacerbate
interpersonal
for desired
maladaptive
communica
in a straightforward
modes
the
to give
are
behavior.
(contingencies
edgment
Poor
control
and relationship
objectives
observable
family
approval.
adolescent
particularly
the functional
developed
by Alexander
fam
and
& Alexander,
2003). More
recent cognitivebehavioral approaches (Dattilio,
2005) restructure family schemas along with
behavioral change and are also effective with cou
ple conflict (see Chapter 10, "Couple Therapy," this
volume).
RECENT DEVELOPMENTS IN
STRENGTHS-BASED APPROACHES
The field of family therapy has shifted increasingly
from a deficit to a strengths perspective and from a
hierarchical stance of the therapist as expert to a
respectful collaboration with family members.
Assessment and intervention are redirected from
problems and how they are maintained to solutions
and how they can be attained. Therapeutic efforts
aim to identify and amplify existing and potential
competencies and resources. Therapist and clients
work in partnership to see new possibilities in a
problemsaturated
situation and to overcome
impasses to change and growth. This positive,
futurefocused stance shifts the emphasis of therapy
from what went wrong to what can be done for
enhanced functioning and wellbeing.
Postmodern Approaches
Postmodern perspectives have heightened aware
ness that clinical views of normality,
health, and
pathology are socially constructed.
Clinicians and
researchers
inescapably bring their own values
and biases and thus coconstruct the patterns they
"discover" in families. Moreover, therapeutic objec
tives are influenced by both family and therapist
beliefs about healthy functioning
(Walsh, 2003b).
Clinicians and researchers need to be aware of their
own implicit assumptions, values, and biases
embedded in cultural norms, professional orienta
tions, and personal experience.
Postmodern approaches are based in construc
tivist and social constructionist views on the subjec
tive experience of reality (Hoffman, 1990). These
approaches were influenced by earlier strategic
systemic models but broke away from many core
principles. While people are thought to beconstrained
by their narrow, pessimistic views of problems, lim
iting the range of alternatives, therapy refocuses
from problems and the patterns that maintain them
to solutions and the processes that enable them. Use
of the reflecting team (Andersen, 1987) in consult
ing team observation of live sessions fosters a more
collaborative approach, whereby families, after the
session, can observe the team in discussion of their
session and then offer their own reflections.
Narrative and conversational approaches empha
size the therapeutic conversation and process of
"restorying" a problematic experience (Anderson,
EVIDENCE-BASED
INTERVENTION MODELS
Family Psychoeducational Approach
Family psychoeducational approaches have been
empirically demonstrated to be an essential compo
nent of effective treatment for schizophrenia
(Anderson, Reiss, & Hogarty, 1986) and find valu
able application with a range of chronic mental and
physical conditions (Dixon et al., 2001; Gonzalez &
Steinglass, 2002; Lefley, 2009; Mcfarlane, 2002;
Miklowitz & Goldstein, 1997; Rolland, 1994). This
approach provides family education and support to
foster coping and adaptation, with concrete guide
lines for crisis management, problem solving, and
stress reduction. The rationale is explicitly based on
the importance of practical information, social sup
port, and problemsolving assistance through the
predictably stressful periods that can be anticipated
in the future course of a chronic illness or major life
transition.
With major mental illness, families are engaged .
as valued collaborators in the treatment process,
with respect for their challenges. This approach does
much to correct the marginalization and blame
laden causal attributions experienced by many fam
ilies of the mentally ill in traditional psychiatric
settings. In the controlled study by Anderson and
colleagues (1986), family intervention combined
with drug maintenance and social skills training dra
matically reduced relapse rates and improved func
tioning of individuals with chronic schizophrenia
and also reduced family distress. The approach is
based on a stressdiathesis model: Environmental
Multisystemic Approaches
With Adolescent Conduct Disorder
Several evidencebased, multisystemic and multi
dimensional intervention models offer highly effec
tive approaches with highrisk and seriously
troubled youth by involving families and larger
community systems (Henggeler,
Clingempeel,
Brondino, & Pickrel, 2002; Liddle, Santisteban,
Levant, & Bray, 2002; Santisteban et al., 2003;
Sexton & Alexander, 2003; Szapocznik & Williams,
2000). These approaches with adolescent conduct
disorder and drug abuse also yield improvements in
Strengthening Resilience in
Vulnerable Multistressed Families
Many families in poor communities, dispropor
tionately minorities, are buffeted by frequent
crises and persistent stresses that overwhelm their
functioning {Aponte, 1994 ). Traumatic losses,
abrupt transitions, and chronic stresses of unem
ployment, housing, discrimination, and health
care can fuel despair. With neighborhood crime,
violence, and drugs, parents worry constantly
about their children's safety. Bleak life prospects,
making it hard to break the cycle of poverty, leave
parents defeated by repeated frustration and fail
ure. Intertwined family and environmental stresses
contribute to school dropout, gang activity, and
teen pregnancy. Too often, agencies and schools
have viewed multistressed families through their
deficits and written them off as unreachable and
untreatable.
A family resilience approach is most needed and
beneficial with vulnerable multistressed families
(Walsh, 2006). When therapy is overly problem
focused, it grimly replicates their problemsaturated
experience. Empowering interventions that enhance
positive interactions, supporting coping efforts, and
building resources are more effective in reducing
stress and enhancing pride and more effective func
tioning. A compassionate understanding of their
struggles can engage parents in efforts to break dys
functional cycles. By tapping family resources and
potential, strengthening bonds for mutual support,
and encouraging their best efforts, families can be
encouraged to gain hope, confidence, and new
competencies to overcome their life challenges.
Maintaining a family focus involves a systemic
view that addresses their problems, repairs and
strengthens bonds, and supports efforts for positive
growth (Madsen, 2006; Minuchin et al., 2006;
Ungar, 2004).
Disruptions and losses in relationships with foster
or kinship care and reunification increase the risk of
youth adjustment problems. A systemic approach is
needed to address the shifts, sustain connections, and
resolve conflicts in role relations, as the following
case vignette illustrates.
'See Chapter 14, "Clinical SocialWork in Situations of Disaster and Terrorism," this volume, for discussionsof these themes.
-Family Therapy
..
~
173
17
Family
4
Therapy
when important
family members
family council,
to discuss placement
laborate
children's
in decision
making
experience
are involved,
options
like a
and col
(Minuchin
et
al.,
2006).
CONCLUSION
This chapter provides an overview of family systems
concepts and methods. In recent decades, the theory
and practice of family therapy has expanded to
respond to increasing cultural diversity, challenging
socioeconomic
conditions,
varied family forms,
changing gender roles, and variable and extended life
courses. As the very definition of the family has
broadened, so too has the definition of family ther
apy, to encompass a wide variety of approaches and
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