Family therapy

Introduction

Family therapy is a form of psychotherapy designed to assess and treat

various psychiatric disorders through-

1)An understanding of how the interactional dynamics of the family

relates to individual psychopathology

2)Mobilization of the family’s inherent strengths and functional resources

3) Restructuring of maladaptative family behavioral styles and

4) A strengthening of family problem solving behaviours.

Goals of family therapy: -

1) To address and reduce dysfunctional behaviours and psychiatric

symptomology of individual family members in the matrix of

interpersonal relationship

2) To solve intra family relational conflict and conflict between the

family and its extended family and social environment.

3) To mobilize family resources and identify adaptative family problem

solving behaviours in the service of addressing the family's present

complaints

4) To enhance the perception and fulfillment by family members one

another's emotional needs

5) To improve family’s problem solving and communication skills

 6) To strengthen the capacity of individual members and the family as a

whole to cope with major life stressors and traumatic events,

including chronic psychiatric and physical illness.

7) To promote appropriate role relationship between the sexes and

between the generations.

Stages of family therapy:-

1) Assessment and identification of problems

2) Intervention

3) Managing the crisis and stabilizing the family

4) Termination

Areas of Family Assessment:

Following we should assess:

1- Family socio- demographic details

2- Family organization or type

(What type of family i.e. joint or nuclear)

3- Family boundaries

(Open, closed, diffused)

4- Leadership pattern and Decision. making process

(Functional, nominal)

5- Role functioning

6- Communication Pattern
 (Direct vs indirect, switchboard, double blind, paradoxical)

7- Coping pattern

(Adequate or inadequate)

8- Reinforcement pattern

(Healthy or unhealthy)

9- Cohesiveness

10- Social support system

(Adequate or inadequate)

11 - Family rituals

12- Family burden

13- Marital quality of patient

14-Family significant life events

15- Family member's attitude towards family members

16-Patient's attitude towards family members

Models for family Assessment:

1) Mc Master Model:

Based on system approach

Emphasis on current family functioning

It consider 6 aspects of functioning

1- Problem solving

2- Communication

3- Roles
 4- Affective responsiveness

5- Affective involvement

6- Behavioral control

2) Process model:

(Steinhaver et al, 1984)

It also consider 6 areas

1- Task accomplishment which is similar to the Mc Master model of

problem solving

2- Role performance

3- Communication

4- Affective involvement

5- Control

6- Values and norms

3) Circumplex Model:

(Olson et al 1983)

It gives emphasis on 2 aspects of family behaviour

1) Cohesion: Cohesion measures the emotional bound that family

members have toward one another. It is similar to enmeshment

disengagement described by Minuchin.

2) Adaptability: Family adaptability is a measure of how far the family

permits change and how far it is characterized by stability.

Family Assessment:
Assessment is a crucial step in any family related problem solving process.

Holman has suggested comprehensive frame work for family assessment

which outlines following major areas which need to be investigated.

• Problem

• Understanding the referral route

• Identifying the systematic context

• Stage of the family life cycle

Family as a system Problem:

A clear understanding of the nature of the problem is essential in deciding

how to deal with it. Some of the aspects are - Nature, origin, duration and

urgency of the problem - Patient's perception and reaction to it - Other family

member's perception and response to the problem - Is any attempt made by

the family members to solve the problem. - Involvement of other system in

the environment.

Understanding of the referral:

Who referred to your client and why? What were their expectations? What

expectations did they communicate to the family? Whether the referral is

routine process and of no major import? Or whether all or some family

members were considerer the need of treatment? It's also important to find out

if clients have been in treatment elsewhere? What happened?

Identifying the systemic context:

Emphasis on current familial and extra familial context of the client.

Family structure:

Regardless of what approach a therapist takes, it's wise to understand

something about the family's structure. What are the actual functioning

subsystems and what the nature of boundaries between them is. Is the nature

of the boundary around the couple or the family? What triangles are present?

Who plays what roles in the family? Communication pattern within family?

School of family Therapy:-

Behavioral family therapy

(Liberman, Patterson, Alexander)

- Short term approach

- Emphasis on overt behaviors that occurs in the family context.

- Rooted in Social learning theory

- Based on assumption that individual behavior reflects reinforcement

patterns that are operating within the family.

- Intrapsychic influences receive minimal attention under this approach

- View of Dysfunction -symptoms:

Maladaptive, symptomatic behaviour is reinforced by-

 Family attention and reward

 Deficient reward exchange (e.g. coercive)

 Communication deficit
 - Through the help of family members we identify the behaviours – both

those to increase and others to decrease

- The primary objective is usually to increase the positive behaviors -by

arranging the things in the family so that desired behaviors are

reinforced. Rewards for adaptive behaviour and no reward for

maladaptive behaviour change interpersonal consequences of the

behaviour.

- Research has shown that behavioral family therapy approach have been

particularly fruitful for working with behaviors problem in children,

including oppositional deficit behaviors and conduct problems.

Psychodynamic model:

(Ackerman, Framo, Lidz, Paul)

View of dysfunction:-

Symptoms are due to family projection process stemming from

unresolved conflicts and losses in family of origin.

Goals of therapy:

1. Insight and resolution of family of origin conflicts and losses.

2. Correct family projection processes

3. Relationship reconstruction and reunion

4. Individual and family growth.

Strategic Family therapy

(Haley, Milan team, Palo Alto group)

Grew out of the communication theory developed in Bateson's schizophrenic

projects.

View of symptom generation or maintenance

 Symptoms are maintained by families

 Unsuccessful problem solving attempts

 Inability to adjust to life cycle transitions

 Malfunctioning hierarchy; triangle of or coalition across hierarchy

 Symptoms are a communicative act embedded in interaction pattern

Techniques:

Reframing: Relabeling a family's description of behaviour to make it

more amenable to therapeutic change; for example' describing some

one as “lazy" rather than "depressed".

Paradoxical Intervention: Therapist directs family members to continue

their symptomatic behavior.

Metaphors: Tales, mythology

Family rituals: Prescribes a specific act for whole family members to

perform, which is designed to change the family systems rule.

Family System Therapy

- (Murray Bowen)
- View of dysfunction- symptom

- Functioning is impaired by relationship with family of origin

- Poor self differentiation: According to Bowen, human relationship is

driven by two counterbalancing life forces: Individuality and

togetherness. How successful people reconcile these two polarities of

human nature depends on the extent to which they have learned to

manage emotionality, is called Differentiation of self. It is rough

analogous to ego strength. It is the ability to be flexible and act

wisely, even in the face of anxiety.

Undifferentiated people are easily moved to emotionality. Their

lives are driven by reactivity to those around them. They have little

autonomous identity; instead they find if difficult to maintain their

own autonomy; especially aroused anxious issues.

- Emotional triangle (Triangulation)

- Nuclear family emotional processes (Emotional fusion):

An excess of emotional reactivity or fusion in families. Lack of

differentiation in the family of origin, leads to an emotional cut off from

parents, which in turns leads to fusion in marriage. It produces one or

more of the following:

1) Reactive emotional distance between the partners

2) Physical or emotional dysfunction in one partner

3) Marital conflict
Family projection process:

Is the process by which parents transmit their lack of differentiation to

their children.

Development of behaviour disorder

Symptoms result from stress that exceeds a persons ability to manage

it. The ability to handle stress is a function of differentiation: the more

well differentiated the person, the more resilient he or she will be and

the more flexible and sustaining his or her relationship. The less well

differentiated the person, the less stress it takes to produce symptoms.

The differentiation process is determined by the quality of the

individual as well as quality of current relationship.

According to Bowen, the understanding factor in the genesis of

psychological problems is emotional fusion, passed from one

generation to another. The overly dependent and the emotionally

isolated person respond with a high level of emotional reactivity to

stress.

Aim of therapy:-

Provide an opportunity for people to learn more about themselves and

their relationship So, that they can assume responsibility for their own

problems.

Therapy:
 Increasing the ability to distinguish between thinking, feeling and

learning To use that ability to resolve relationship problems are the

guiding principles. Lowering anxiety and increasing self-focus (Ability

to see one's own role in interpersonal process, is the primary

mechanism of change)

Technique:

 Genogram: a systematic diagram of the family. The main function of

the genogram is to document developmental stressors in a three

generational family system. It is used to trace relationship conflicts; cut

offs, and key triangles. This process of collecting information is

sometimes therapeutic in and of itself.

 Process Questioning: Each family member asked a series of

questions aimed at toning down emotion and fostering objectives

reflection. The process question is aimed at calming anxiety and

gaining access to information on how the family perceives the problem

operate. If this decrease anxiety, people are better able to think clearly.

 Role Play/ Relationship Experiment:

 Coaching: Coaching does not mean telling people what to do. It

means asking questions designed to help people figure out family

emotional process and their role in them.

Structural family therapy:

(Minuchin)
 Important tenets of this approach is that every family has a structure

(recurrent patterns of interaction that define and stabilize the shape of

relationship)., and this structure is revealed only when the family is an action.

The basic concepts of this approach were:-

Boundaries:- emotional and physical barriers that protect and enhance

the integrity of individuals, subsystems, and families.

Types: Closed, Open, Diffused

Subs stem: - Units of family based on function. It is determined by

generation or sex also.

Coalition: an alliance between two persons or social units against a

third.

Main psychopathology in family:

Disengaged and enmeshed families:- Boundaries are diffused and

family members become dependent on one another. Interviews parents

create difficulties by hindering the development of their children and

interfering with their ability to solve their own problems (Over

involvement).

A frequently encounter pattern is the "enmeshed mother/

disengagement father syndrome".

Goal of therapy:

 Structural change and problem solving:

 Effective hierarchy
  With enmeshed families: the goal is to differentiate individuals and

subsystems by strengthening the boundaries around them.

 With disengaged families: the goal is to increase interaction by making

boundaries more permeable.

Psychoeducational Approach:

(Fallon, Leff, Anderson and Hogarty Mc Farland)

View of normal Family functioning:

 Uses Information to problem solves clear communication,

Flexible coping skills.

 Acknowledge, respect, and view members positively.

View of Dysfunction-Symptoms

 Dysfunctional response to offspring's illness

 No, or distorted, information about the illness

 Poor communication

 Critical or over involvement or both

 Unable to problem solve

Goals of therapy:

 Provide information

 Define problems clearly: generate and apply solutions

 Reduce over involvement and criticism

 Teach coping strategies

Indication and Contraindication of Family therapy

Indications:

- Problems in relationship within family (e.g. marital discord, existence of

communication or generation gap)

- Interdependence of symptoms (wife depression being contingent on the

husband alcohol consumption and vice versa)

- Development of stress in other family members improves (development

of depression in wife following husbands giving up drinking, leading to

his improved participation in family matters.

- Failures of individual therapy (may be because family tensions have not

been handled)

Contraindication of family therapy:

Family factors:

 If key family members are unavailable for geographical or

other reasons or are completely unmotivated to become

involved in the treatment.

 Families having major psychopathology in more than one

family member.

 When the family is referred by an agency such as a court or

school. In such cases there may be hidden agenda for

 example- To provide a child from being expelled from a

school, rather than any real wish to change.

Therapist factors:-

 Lack of commitment Inflexibility

 Therapist having problems similar to the patient's problem

Lack of empathy and adequate training

 Therapist having social relation with the client.