Speaker: Dr. Pavan kumar Chairperson: Ms.

Malarmathi

Introduction to Family Therapy Normal family functioning Schools of Family Therapy Systemic F.T. Strategic F.T. Structural F.T. Extended F.T. Cognitive Behavior F.T. Psychodynamic F.T. Experiential F.T. Psychoeducation Indications and contraindications Efficacy of Family therapy in various disorders Recent trends

Vastly expanded and gained wide acceptance in last 4 decades. 42% of people who sought professional help for psychological problems viewed their problems as related to a marital problem and another 17% viewed as pertaining to family relationships. Gurin, Veroff and Feld (1960)

Ultimate goal- change in family process

Additional goal change in the behavior of an individual or in a broader dimension of relational life ex: marital satisfaction.

Family therapy when more than one member of a family are seen together in psychotherapy. Conjoint FT-when seen at one time.

Concurrent FT- when seen in different sessions

Excludes therapies that focus on single symptomatic client in family and social system (eg Bowen therapy)

Any psychotherapy endeavor that explicitly focuses on altering the interactions between or among family members and seeks to improve the functioning of the family as a unit or its subsystems, and/or the functioning of individual members of the family. Gurman et al (1986)

Family therapy is a mosaic of techniques, all of which have the shared goal of direct alteration of maladaptive family processes.
Controversy regarding couple therapy to include in FP(family subsystem) or not (as different skills applied).

Classified along 2 axes

1st consisting of who is seen in treatment( eg. Individual, couple, nuclear/extended family) 2nd the theoretical perspective of which the therapy centers (eg. Structural, strategic, object relations, or a type of integration).

Child guidance clinics of early 1900s - Adler's involvement of parents in the therapy for their children, represented a significant departure from the dyadic psychoanalytic model prevalent at the time. Nathan Ackerman founder of family therapy

Earliest CT and FT framed as direct extension of existent models of individual therapy.

FT leapt to prominence through the work in 1950s&60s by Nathan Ackerman, John Bell, Ivan Boszormenyi-Nagy, Murray Bowen, James Framo, Jay Haley, Doanld Jackson, Salvador Minuchin, Virginia Satir, Carl Whitaker, and Lymen Wynne
Prominent view- causality is best conceived of as a circular process in which behavior is seen as interdependent and subject to mutual influence.

Family was viewed as the principal locus of the problem, central in its development, and the most appropriate context for treatment.
Theories(schools) developed in backgrounds of psychoanalysis, behavioral, social systems(structure overcoming family homeostasis or integrational process), anthropology, communication, hypnotherapy

Shift from Schizophrenia to other disorders. In 1970s & 80s FT passed through the phase emphasizing differences across the many distinct schools that emerged. No objective observers- therapists become part of the system being influenced by it as well as influencing it.

An integrative viewpoint that includes not only family methods of intervention but also at the level of individual and larger system.

Provides for the needs-material, emotional, spiritual of family members.

Basic processes involves integration, maintenance and growth of family unit. Normality range- asymptomatic functioningstatistically average- optimal functioning. Normality defined by social, temporal context & needs adaptation to internal and external demands over the course of family life cycle.

Barnhill (1979): 4 basic themes-(8 dimensions)

Identity Processes
Individuation Vs Enmeshment. Mutuality Vs Isolation.

Change
Flexibility Vs Rigidity. Stability Vs disorganization.

Information Processing
Clear Vs Unclear or distorted perception. Clear Vs unclear roles or role conflict.

Role Structuring
Role reciprocity Vs unclear or conflictual roles. Clear Vs diffuse or breached intergenerational boundaries.

Fleck(1980)- 5 parameters of family functioning Leadership: parents personality, roles, disciplinary style etc Family Boundaries: ego, generation and familycommunity boundaries. Affectivity: interpersonal intimacy, tolerance to each others feelings, unit emotionality etc. Communication: consistency, expressiveness, responsiveness to each other etc Task/goal Performance: nurturance, behavior. Control & guidance, crises management, adaptation etc.

Task accomplishment problems.

Communication problems.

Role problems.
Behavior control problems. Poorly functioning sub-systems & boundary problems. Supra-system problems.

Honeymoon

Toddler

Empty home

School going child

Retirement

Adolescent

Launching the child

 Evidence
Evidence

of family dysfunction

that family dysfunction related to clinical presentation. & interactional problems

Relationship

Failure

of other treatments
Evidence base

Favorable

 Practical
Poor

/ geographical limitations.

therapist match.

Severe

medical illness.
psychiatric disorders.

Incapacitating Escalating Working

physical harm.

with divorced parents.

Most central being the influence of the social system in influencing individual behavior. GENERAL SYSTEMS THEORY (Von Bertalanaffy, 1969)- understanding all systems, animate and inanimate with central tenet that whole is more than the sum of its parts. To understand any part (eg. An individual), one must grasp its relation to the whole of which it is a part( family).

Equifinality- suggests that there are many ways of reaching particular configurations within the system and that the particular pathway by which a configuration has been reached doesnt matter. Applied to family systems, equifinality focuses concern on the state the family is presently in and not how the family reached that state.

Behavior is understood as a function of the CONTEXT in which it is conceived. Classic ex- the meaning of seeing a man quacking at ducks is significantly altered by the knowledge that this man is Konard Lorenz engaged in experiments about imprinting.

Severe mental illness was seen as product of behavior that made sense in a particular context(eg within family process), although it appeared to make little sense outside of that context. identified patients- family members displaying psychopathology or other problematic behavior appropriate in family context, so family therapy is most appropriate method of bringing change. (X) dismissal of biological basis of severe mental disorder.

Circular paths of causality- Rather than focusing on linear pathways of actions followed by reaction, attention centers on recursive patterns of mutual interaction and influence. The system, not a single person, is responsible for the behavior that is maintained through such circular pathways. (X) family violence instance where individual responsibility and linear arcs of causality otherwise batterer and victim are coequal in responsibility for violence behavior.

CYBERNETICS- science of communication and control in man and machine, developed by Weiner et al. Systems are viewed as self- correcting to maintain a steady state(homeostasis), influenced by feedback either +ve or ve. Every FT was profoundly influenced by the idea that human systems were homeostatic, moving toward the reduction of change. As a result most 1st generation FT were based on the notion that powerful interventions needed to reorganize the family.

Systemic thinking has given more weight to MORPHOGENESIS, the natural force moving the system toward change. Initiating the process of small changes is likely to kick off a positive chain reaction, while in homeostatic models most powerful interventions needed to produce change. Similar process- AUTOPOESIS, (Maturana and Verela,1980)- internal structure of the living system determines its behavior, therapist can only perturb the system to make changes that the client system itself produces.

Couple and Family therapies can be divided into following categories on the basis of emphasis. Structural Strategic Cognitive-behavioral Psychoeducational Intergenerational Psychodynamic Experiential Narrative and Integrative schools of FT

Remains most influential school with in family therapy aiming ultimately at restructuring the family system.
Developed by Salvador Minuchin largely drawn purely from systemic concepts. Emphasizes the power of the social system as manifested through family structure.

Given the homeostatic vision of systems as base of therapy, therapists create powerful in-session experiences to work to alter the familys organization.
Minuchin, by family structure means the regulating codes as manifested in the operational patterns through which people relate to one another in order to carry out functions

Three primary dimensions of structure are boundary, alliance, and power. Boundaries are rules defining who participates and how, who is in and who is out of an operation, regulating contact. Strength of boundaries vary, ranging from rigid (families act like they have little to do with each other), resulting in disengagement, to very permeable (violating the boundaries and intruding into functions of others), resulting in enmeshment.

Structural FT aims to move families away from the extremes of enmeshment and disengagement. Alliances are the joining or opposition of one member of a system to another in carrying out an operation. Alignments become dysfunctional when they become fixed and unchanging (stable coalitions) or when they primarily cross-generation.

Triangulation describes the process of two people demanding that a third join with them against the other.
Structural FT aims to create alliances that are functional(eg parents with one another), while at the same time not becoming rigid.

Power describes the relative influence of each family member on the outcome of an activity, may be with older generation, one individual or coalition.
Power is seen best held in the hands of an executive (eg a parental coalition), but in such a fashion to leave everyone with some degree of power.

Therapist promotes family members habitual patterns of relating (called enactment) with the family. Emphasis in joining with the family through tracking (adopting the symbols of family life), accommodation (relating to the family in congruence with the familys patterns), and mimesis (joining with the family by becoming the like family in manner or content).

Symptomatic change in identified patients is assigned a much less important role than change in the structure of the system
Criticism- gender based of some assumptions in structural FT, as approach on equifinality so limited concern with history or internal process of individuals. Minuchin (1996) has recently moved to a more gender aware version and acknowledged importance of history

Most purely systemic of the family therapies.

From the strategic viewpoint, change is a discontinuous process.

The goal is to intervene briefly, find a new way of functioning that works better, and promptly end the treatment. Paradoxical interventions - directives are offered which if acted on, would move the family against the direction in which it is directed. Reframing- active efforts by the therapist to create a new and different understanding of old events that has a more benign meaning. MC intervention in CT and FT.

Use of team approaches, utilizing observers behind one way mirrors as part of intervention process, typically offering commentary or directives to the therapist and family. Change, not learning about the change process, is centre of attention- altering feedback cycles, but not providing insight about such cycles.

TYPES:

MRI (Mental Research Institute) / Palo Alto model Haleys problem solving therapy Milan systemic therapy Solution-focused therapy.

First systems-based strategic model within FT

Developed by Jackson, Watzlawick, and Weakland.

Derived from a mix of systems theory, cybernetics and the study of communication process.
Always remain brief & focused, with therapist attachment isnt long term and terminated as soon as problem resolution is initiated.

Problems are viewed as a natural part of family life that families regularly deal with on their own.
Need for intervention is seen as stemming not from the problem itself, but how family members treat the problem. When families efforts to solve problems(more of the same), changes in behavior, termed firstorder change which unlikely resolve the problem and make even worse.

Therapy focuses on second- order change, an alteration of rules that lie beneath the behaviors maintaining the problems.
Reframing and paradoxical interventions most powerful tools for initiating 2nd order change. Exemplar of strategic FT, rarely practiced in pure form and lacks empirical support.

Haleys and Mandanes strategic use of paradoxical techniques with goals that typify structural FT. Emphasizes grasping and working with the function (struggle for power and control) that behaviors serve within the system. Derived from the hypnotic work of Milton Erickson, aimed at increasing suggestibility and openness to change. ex pretend technique, a paradox technique that suggests possibility of overt control over patterns thought to be out of conscious control.

specific observation by therapist on triangles(who supports whom in interaction)

and hierarchy (who has what power), directives to family in new and different behaviors. Highly controversial in view that identified patients carry symptoms due to family dysfunction and a denial of existence of mental illness ie not due to biology or individual psychology.

Developed in Milan, Italy by Selvini- Palazzoli, Boscolo, Cecchin, Prata and others Team behind a one way mirror, forms a hypothesis over the family, to be modified over the course of treatment. Intervention through positive connotation or prescription of ritual. Positive connotation- reframing behavior in positive light, suggesting how behavior serves the goals of the system.

Rituals prescribed to exaggerate or move against rigid patterns in the family. Most rituals have ironic quality and engender confusion.
Ex: odd and even days- control given to each parent on alternating days.

Boscolo and Cecchin variant- circular questionsquestions used to learnt about differences in the family that might provide clues to recursive family patterns. Curiosity is the essential ingredient in circular questioning.

The aim is not to move the family toward a specific goal, but to initiate thought and conversation in order to create greater understanding of how the present situation and family behavior,
what the systemic patterns are that keep the family from resolving their difficulties and what are most productive pathways toward change.

Selvini- Palazzoli variant- disturbed patients were inevitably caught up in dirty game, a power struggle between parents in which patients symptoms help support one parent. the invariant prescription- the therapist suggests to parents that they tell family members that they have a secret and go out mysteriously without warning other family members, and they then observe the familys reaction.

Aims to help strengthen the alliance between the parents and enable understanding of dysfunctional patterns in the family.
Milans approach though highly influential, small number practice and little empirical testing available.

DeShazer, Berg, OHanlon, and Weiner-Davis. Assume that clients want to change and reject the notion of deeply ingrained pathology These approaches seek to introduce ways of thinking about and facing difficulties that are different and can kindle the familys own process of resolving their difficulties.

Employ miracle question- how would be, if all your problems solved suddenly in a night when your are asleep.
One favorite technique is to look for exceptions, times when problems have not been present or overcome. To nurture and help clients notice small changes from which they can build larger ones

All these techniques help clients begin to think in terms of solutions and ability to resolve difficulties rather in terms of problems and ones difficulty in resolving them

The positive focus and optimistic frame of these models has proven most welcome to families and therapists alike.
Criticism- repetitive use of same few interventions (miracle question), least studied.

Behavior principles in the treatment of family systems. Utilized in child behavior problems (esp CD and child delinquency) and couple difficulties(marital dissatisfaction). Thoughts and behavior are central to all aspects of functioning, the most efficacious pathways to change directly address dysfunctional thoughts and behavior patterns.

Classical and operant conditioning, with latter assumed great importance. Reinforcements central to operant conditioning, social learning theory(directly/modeling) shape behavior.
Social exchange theoryindividuals strive to maximize their outcomes, to increase the rewards they receive and decrease the costs. (Thibaut and Kelly,1959)

Behavior from one person is viewed as likely to be met with reciprocity to behavior from another, so social exchanges can become mutually supportive or coercive(punishing). Couple dissatisfaction- product of low level of positive reinforcement and high level of coercive exchange within relationship

skill training aims at providing knowledge about this and to engage in appropriate behavior. Cognitive theories of CBT emphasize the development and maintenance of dysfunctional or irrational thought processes, and direct efforts to alter these cognitions through learning in therapy.

Reciprocal influence(Patterson & Chamberlein) of child and parent in CD, therapists has to remain sensitive in too frequent teaching behaviors that promote noncompliance.
Behavioral couples treatments empirical support , at least in short term effectiveness.

Not only behavior , but involving feeling states, lead to formulation of noncontingent loving behavior called caring days or love days in CT.
Sex therapy in CT sensate focus by Masters and Johnson anxiety is antithetical to sexual response and through classical conditioning, relaxation can replace anxiety

Parent training or CT in CBT involves assessment of thought and behavior patterns connected to target behavior, functional analysis of problematic behavior, formulation of plan specifying problem solving skills training (in CT), contingencies home token economies, point systems- preference for positive reward over punishment in shaping behavior.

Functional FT( Alexander and Parsons) for adolescent delinquent behavior examine function and to enable engagement and cooperation in treatment.
Validated psychotherapies particularly approaches to child and adolescent problems.

Based on the notion that- Syndromes that seriously impair functioning have a biopsychosocial basis. Establish a collaborative partnership with families who suffer from mental disorders, providing them with the kind of information and skills, most needed for coping.

Eclectic mix of individual and family therapy that have relevance to particular syndrome as well as psychopharmacological interventions.

Psycho educational FT developed in context of schizophrenia and extended to other disorders most notably manic depressive disorder . Western psychiatric institute in Pittsburg and UCLA, developed psycho educational methods featuring medication

for the person with schizophrenia along with education, survival skills workshops to families regarding expressed emotions

With both these methods, expressed emotion has been decreased, compliance increased, and recidivism and symptoms decreased in index patient.

This work extended to families dealing with manic depression ( Milkowitz and Goldstein).

The strong evidence for the efficacy, lack of evidence that FT works in these samples without the use of medication suggests psycho educational form of FT is clearly superior to earlier variety.

Bowen family systems therapy incorporates systems therapy along with a unique language for considering the relationship of individual with family. Concept of differentiation of self (thoughts and feelings) from family processless susceptible to the pathology distinguished from cut off (establishment of rigid boundaries that minimize contact with family viewed as innately problematic)

In Bowens theory ,individual development is largely shaped by the family system.

Undifferentiated ego mass of beliefs and feelings are transmitted through family projection process across generations In Bowen family systems therapy, each member of the family involved to increase their ability to manage their own anxiety and much of the work focuses on the relationships clients have with their families.

Family of origin is typically not seen directly in treatment , but examined through forays outside sessions In which the client learns about family processes, experiences them and find new ways to cope with them. Coaching- therapist helps to examine thoughts and feelings that emerge.

Exploration- involves direct contacts with living relatives and efforts to learn about and experience feelings in relation to deceased family.
Much of Bowen family systems therapy is conducted with only a single client in the office, though the work is principally centered on their family relationships. It represents a bridge between individual and family therapy.

Basic notion- active dynamic internal process within individuals. Psychodynamic approaches share the belief that unconscious mental process are extremely important and that early experience has a crucial influence on later behavior and experience. Psychodynamic FT retained its individual therapy counterpart an emphasis on processes that occur within individuals

Creating an appropriate frame, understanding transferences in much relation to other family members, particularly spouses,

as in relation to the therapist, counter transference, projective identification

(therapist induced to feel or behave as the client has in past or as others have behaved and felt toward the client).

Psychoanalytic therapies though not used in pure form, have been used in a variety of integrative approaches. variant insight oriented CT had promising future.

Whitaker, Satir and Greenberg and Johnson Felt experience- restoring liveliness and connection in the therapy The primary instrument is the therapist, who uses self as an instrument toward change.

Whitaker utilized a wide array of techniques, ranging from direct commentary to physically wrestling with clients, all aimed to fight emotional deadness.

Satir employed exercises from the human potential movement(belief that through the development of "human potential", humans can experience an exceptional quality of life filled with happiness, creativity, and fulfillment)
Greenberg and Johnson utilize methods of emotional focused interaction between couples derived from Gestalt therapy

Michael White, Anderson and Goolishian, Combs and Freedman, Hare-Mustin Social constructivism knowing is socially constructed through language and discourse, and depends on the context of the observer. Difficulties are envisioned as the product of stories that have been socially created and can be reconstructed.

Problem-oriented descriptions are replaced by stories of accomplishment. Rather than merely opening discourse, these approaches also accent the feeling of repressed voices.
Much of the work is done with individuals, with only passing references to the family system.

Merge the raw material of the various approaches. This merger occurs at three distinct levels: theory, strategy, and intervention.
Therapists can build a personal method. Moultrops and Lebows work suggests guidelines for each therapists model development, offer examples of conceptions focused on the therapist as an agent of integration

Jacobsons couple therapy, Liddle, Dakof, and Diamonds treatment for adolescent drug abusers and their families, Pinsof s problem centered therapy or Gurmans integrative marital therapy.
Feminists(Goldner, Hare-Mustin, Aponte..) integrated therapies giving importance to race, class and gender. Research promising and proven highly effective.

 Initial contact Establishing rapport Defining desired outcome Review history, determine present

stage & genogram Assess current functioning Develop diagnostic formulation Offering feedback Arranging further clarifications & referrals Treatment proposals

developmental

Wiley - Family Therapy - Concepts, Process and Practice - 2nd Edn

Behavioral approaches largely have extensive research support, particularly in treating childhood and adolescent CD, marital dissatisfaction, and adolescent acting out.

Structural approaches also have considerable support, particularly in child and adolescent CD.
A experiential approach to CT, emotionally focused therapy, insight-oriented therapy have garnered research support.

Psycho educational treatments of schizophrenia,

CBT of depression, Multi-systemic treatment and functional family therapy for adolescent delinquent behavior, and

Multi-dimensional family therapy for adolescent drug abuse have considerable research evidence

Very little research support for a variety of widely practiced CT and FT including Bowen, narrative, humanistic, strategic, and solution focused therapies CT and FT have been demonstrated considerable value in treating
depression, anxiety disorder, panic disorder, schizophrenia, alcoholism, and marital adjustments in adults and CD, autism and drug abuse in children and adolescents.

A shift has occurred in which interpersonal processes, feedback loops, and systems role in problem generation

And resolution are still emphasized, but attention broadens to include individual functioning, the larger social system and other levels of anlaysis. Boundaries among individual, CT and FT and between schools of FT are blurring with development of more integrative therapies.

Biology is clearly emerging in literature as imp variable of FT, the field of family systems medicine have come to occupy much attention. Very strong emphasis on intervention strategy Tendency to develop specific variants of treatment to respond to the specific issues in particular kinds of cases has emerging. Much attention on meaning and methods for intervening in family violence has been gaining prominance.

Gender and culture have emerged as vital considerations in shaping practice. Impact and relationship of systems larger than the family such as schools, legal system, poverty and peer groups, On family dynamics Multisystemic treatments targeting multiple systems are beginning to emerge.

An increasing emphasis on a life cycle perspective, whether the family is in developmental process and shape interventions accordingly.
Much more emphasis on health, normality and resilience as opposed to homeostasis, resistance and pathology.

Culturally inappropriate Minimal father involvement Poorly defined role for siblings Counter transference. Inaccurate formulation Inattention to influential relatives

 Reluctance

of family therapists to accept current diagnostic systems. Power of biological wave. Managed care limitations. Impending fragmentation of care. Absence of valid nosology/ classification of relationship disorders. Absence of objective outcome assessment.

Systems formulations of family process and family systems orientations to psychotherapy have become prominence since 1960s. Approaches to CT and FT are increasingly integrative, integrating a range of concepts and intervention strategies and including a focus on the individuals within the family as well as on the broader social system in which the family resides. Research supports the tenets of systems theory as an explanatory set of concepts for family processes.