family therapy 101

8/7/2019 Family Therapy 101

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Nuclear unit is a modern concept

Property concerns trump love

Rearing of children

Emotional support of spouses

Maternal instinct-love your children; why risk it?

Family Development Within a

Historical Context


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Todays nuclear family result of urbanization andindustrialization

Autonomy and authority of family recent occurrence

Community played large role

Family Development Within a Historical

Context


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Why is this important? Impact of public policy, rapid

economic and social change

Where is the family unit headed?

Factors that may govern family change

Family Development Within a Historical

Context


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1920s & 30s: increasing concern for family unit, childneglect, divorce and re-establishing the gender roles

Two major forces in therapy : Freud and Carl Rogers

Common belief that psychological problems arise fromunhealthy interactions with others.

Humble Beginnings

(context sets the stage)


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Belief that internal conflicts can best be dealt withthrough private relationship between patient andtherapist

Freud convinced that neurotic conflicts are spawnedin early interactions between children and their family

Sought to isolate the family from treatment in orderto liberate patients from these pathologicalinfluences (as a disease in the psychoanalyticoperating room)

Humble Beginnings


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Rogers-saw an innate drive towards self-actualization

This instinct gets subverted by others who tend torespond to us in terms of their own needs

They give the approval we crave only if we do whatthey approve of

Patients learn not what to do that is best for them butrather how to avoid displeasing others

Humble beginnings


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Loyalty to family was encouraged but individualitywas being promoted at the same time.

Full-time mothering was applauded but overbearingmothers were blamed for their childrens behavioralproblems.

Family therapy was created to treat the enmeshedsmothering families; most of the pioneers focused onways to understand and intervene with overly tightfamily bonds causing problems for individuals.

Humble Beginnings

(cont)


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Greater concern today with securing family bonds

Models had to adjust to changing cultural context

History of family therapy can be organized into threegenerations

First generation-radicals who challenged the status quoincluding Bowen, Minuchin , Haley and Bateson

Humble Beginnings

(cont)


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The second generation was the challengers whoquestioned the assumptions of the founders anddeveloped their own models (solution orientedtherapy, narrative therapy, medical family therapy)

The third generation developed specialized, evidence-

based models for particular populations (multi-systemic therapy, multi-dimensional family therapy)

Humble Beginnings

(cont)


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Based on Systems Theory which is concerned withhow parts relate to each other and to the wholesystem (society)

Developed primarily at the Philadelphia ChildGuidance Clinic under the leadership of Salvador

Minuchin Emphasis is on structural change

Therapist is an active agent

Structural Family Therapy


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Wiltwyck experience

Focus on Intrapsychic conflicts not leading to change

In 1965, Minuchin appointed director of PhilidelphiaChild Guidance Clinic



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Primarily a was of thinking about and operating inthree related areas:

The family- conceptualized as a living open system. Inevery system the parts are functionallyinterdependent in ways dic-tated by the

supraindividual functions of the whole.



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A family is a living system-in constant transformation

Homeostasis-patterns that assure the stability of thesystem

Complementarity -balancing roles so as to maintainequilibrium. Moderate complementarity enables

spouses to divide functions and support and enricheach other.

Steps in a dance

Drop your end of the rope



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woman who sought therapy for depression

Husband who urged wife to seek therapy for frigidity

Woman who demander her husband stop drinking

Some people are able to accept a needy partnerrather than a capable adult



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The presenting problem-the problem as defined bythe family for which they are seeking a solution

Function of the problem

The process of change-the re accommondation thatthe family undergoes to adjust to a different set of

environmental circumstances



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Subsystems-groupings of perform various functions.Every individual is a subsystem and dyads or largergroups make up other subsystems. Determined bygender, age or common interests

Can be a member of multiple subgroups

Alliances versus coalitions



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Spousal Subsystem: created when two people marryand create a new family. Requires a process ofaccommodation and negotiation . In a healthy spousesubsystem, each gives and takes without losing theirindividual identity. Has specific functions.

(family of origin influence) Functions of a spousal subsystem???



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Parental Subsystem-executive- the second subsystem

which emerges with the birth of a child. Differencesin parenting styles and preferences may emerge andneed to be negotiated.

Is the system to deal with issues and functions relatedto child rearing

Each spouse has the challenge of supporting andaccommodating the other in order to provide anappropriate balance of firmness and nurturance

balance beam, personal history of abuse



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Sibling Subsystem- allows children to be children andto experiment with peer groups

Their security is grounded in the strength of both thespouse and parent subsystems

Children develop a sense of belongingness and a

sense of separateness Children require different types of parenting at

different ages



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Boundaries-rules that define who participates withwhom and in what kind of situations. They areinvisible barriers that surround individuals andsubsystems, regulating the amount of contact witheach other. They protect the separateness and

autonomy of the family and its subsystems.



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Children should not participate in adult arguments

Oldest daughter has more privacy rights than heryounger siblings

No phone calls permitted during supper



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Three main types of interpersonal boundaries

A) Rigid Boundary-overly restrictive, permitting littlecontact with outside systems. This results indisengagement and isolation

Little mutual support or affection

B) Diffuse boundary- enmeshed subsystems offerheightened mutual support but at the cost ofindependence and autonomy.



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Types of Boundaries (cont)

C) Clear Boundaries maintains privacy forsubsystems and establishes a clear hierarchicalstructure in which parents exercise a position ofleadership. A clear boundary enables the children tointeract with their parents but excludes them fromthe spouse subsystem.

Impact of focus on childrens rights, undermining ofhierarchy

Structural FamilyTherapy


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Goals of Therapy:

Structural family therapists believes problems aremaintained by dysfunctional family structures

Therapy is directed at altering family structure so thatthe family can solve the problem

The goal of therapy is structural change. Problemsolving is a by-product of this change.



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When does Jimmy turn aggressive?

What happens immediately before?

how do others react to his misbehavior?

Do mother and father agree on how to discipline him?

N.B. Hospitalization of the identified patient hindersefforts to restructure the family due to theconfirmation of the familys definition of the problem



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By altering boundaries and realigning subsystems, thetherapist changes the behavior and experiences ofeach family member

The therapist helps modify the family functioning sothat family members can solve their own problems



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The therapist is forthe people in need of help

Therapist is againstthe system of transactions thatcripple them



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It is a dynamic therapy in which symptom resolution issought , not as an end in itself but as a result oflasting structural change

The most effective way to change symptoms is to

change the family pattern that maintains them Challenge observed processes



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The analyst changes the structure of the patients

mind whereas the structural family therapist modifiesthe structure of the patients family

The goal of structural family therapy is to facilitatethe growth of the system in order to resolve

symptoms and encourage growth in individuals whilealso preserving the mutual support of the family



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One of the most important general goals is the

creation of an effective hierarchical structure.

Parents are expected to be in charge, not relate totheir children as equals

A general goal is to help parents function together as

a cohesive executive subsystem What then are the implications for nursing staff in

terms of carrying out their roles on the CAMHP unit?



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Therapists Role: to support while challenging, to

attack while encouraging, to sustain whileundermining, to be for the people in need of helpwhile against the system of transactions that createdand/or perpetuate the problem



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Techniques:

Joining and accommodating

Working with interaction

Diagnosing

Highlighting and modifying interactions

Boundary making

Adding cognitive constructions


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Joining and Accommodating:

Families have firmly established homeostatic patterns

Effective therapy requires strong challenge andconfrontation

Therapists earn leverage by demonstrating

acceptance and understanding of family membersand by displaying competence



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Joining and Accommodating (cont)

Family outnumbers the therapist

Must disarm their defenses and disarm their defensesthrough warmth, understanding and acceptance



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Joining and Accommodating (cont)

Useful at beginning to greet family and ask for eachpersons perception of the problem

Failure to join and accommodate produces tenseresistance



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Working with Interaction

Family dynamics are what happens when the family isin action, not what they say happens

Get family members to talk among themselves

Understanding the landscape



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Working with Interaction (cont)

Families may demonstrate enmeshment by frequentlyinterrupting each other or constantly arguing

Disengagement may be revealed as a husband sitsimpassively while his wife cries



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Diagnosing

This implies having a formulation upon which to basestrategies for change

Diagnosis broadens the problem beyond individualsto family systems



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Diagnosing

Diagnose in a way as to describe the systemicinterrelationships of all family members

Using concepts of boundaries and subsystems, thestructure of the whole system is described in a way

that points to desired changes Diagnosis is an ongoing process



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Highlighting and Modifying Interactions

Once a family begins to interact, problematictransactions emerge

Requires a focus on process, not content

Mindset of circularity, not linear

Goal is to highlight and modify this pattern ofinteraction

This requires forceful intervening


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Adding Cognitive Constructions

Using words and concepts to alter the way familymember perceive reality

Reframing, use of metaphors, provocative statements



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CRITIQUE

Lacking in feminist -does not address powerimbalances

Recognizing that behaviors occur in circular patternscan serve to undermine the responsibility of some

family members



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CRITIQUE

Concepts of enmeshment and engagement fail toconsider the different parenting techniques utilizedby people in different cultures

While structural family therapy acknowledges the

impact of social context, it places little emphasis onthe larger social environment as a focus of treatment



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Emphasis on differentiation-describes how family

process fosters or diminishes individual diffrentiationof self

Families with features of emotional fusion andtriangulation foster anxiety and low differentiation of

self Use of genograms to track the emotional history of

family of origin

Murray Bowen


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Highlighted the multigenerational transmission of

habitual family patterns Focus of therapy is to break these habitual patterns

Murray Bowen


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Palo Alto team developed this approach

Heavily influenced by Milton Erickson

Hybrid of Ericksonian and Structural family therapy

Developed primarily by Jay Haley and Chloe Madanes

Strategic Therapy


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Symptoms viewed as metaphorical acts involving a

contract between two or more family members Can provide a way to protect or stabilize a family such

as when a child acts out to distract the parents fromtheir marital problems

Strategic Therapy


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People maintain problems by how they try to solve

them Insight is not necessary for change to occur

Intervention is directive and brief

Strategic Therapy


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Primary intervention is reframing-school phobia is

labeled as school refusal, depression as sadness Best known for use of paradoxical interventions such

as restraining change, cautioning families to slowdown progress less there be negative consequences

Creative in working with resistance

Strategic Therapy


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Therapist may prescribe symptom

Credit always goes to family for any progress

Powerful tools but minimal collaborative engagement

Strategic Therapy


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Grew out of strategic family therapy

Avoids discussing history about the origins of theproblem and instead focus on goals, resources andexceptions to the problem behavior rather than onthe problems themselves

Solution Oriented Therapy


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Michael White and David Epston

Postmodernism, 1980s

Favors a constructivist emphasis on narrative, storyand the cocreation of reality over theory and expert

Narrative Therapy


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See people as developing problem-saturated

descriptions of their lives which are reinforcedthrough traditional diagnosis and problem-orientedtreatment

Goal of therapy is to free people of oppressive stories

in their lives, stories derived from the dominantculture

Narrative Therapy


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The therapists job is to deconstruct this narrative and

help the patient reclaim ownership of her life Therapy becomes a form of conversation that

involves re-storyingin which patients locate andregenerate alternative narratives that create an

altered sense of self that is separate from theproblem.

Narrative Therapy


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Therapy does not diagnose. Rather, it focuses on

social scripts Multi-cultural pro-feminist, progay, prolesbian and

opposed to social oppression in all its forms

Therapists stance is positive and curious, beingfrequently impressed with what the client offers up intherapy

Externalizes the problem the problem is theproblem and the person is the person

Narrative Therapy


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For example, the therapist might ask about a time where

the depression was not in charge and how did the clientmake that happen

The goal is to liberate the family from their constrainingconstructions so they can create alternative ones, can re-author their lives.

Takes the fight to the street by accessing social networksof patients and assisting them in making stands against theculture and the mainstream treatment system

Narrative Therapy


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A series of studies showed that psychoeducational

family treatment was effective in preventing relapseand rehospitailzation among people withschizophrenia

They accept the biological base for schizophrenia

View the family environment as important as apossible precipitant and as a risk or supportive factorfor maintaining treatment gains.

Psychoeducation Family Therapy and

Medical Family Therapy


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Psycho educational family treatment focused on

expressed emotions orcritical overinvolvement ofparents vis a vis their children with mental illness

Help families find low-key non-reactive limit settingalong with other strategies to support a healthy

family environment


Medical FamilyT

herapy


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Like family psychoeducation, medical family therapy

embraces a biopsychosocial framework for treatment Expanded the scope of family therapy beyond work

with mental health problems to include the wholescope of health problems

Medical family therapy is a metamodel which means itis an overarching framework within which a therapistcan use his or her preferred therapy model.


Medical Family Therapy


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Takes mental health seriously and sees oneself as

working as part of a team of multidisciplinaryproviders rather than as a sole operator


Medical FamilyT

herapy


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Theory in Action


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Case One: THE BOY WITH THE STRANGE APPETITE

aka

THE BOY WITH TERRIBLE BREATH

Therapy in Action


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Case Two: TRY NOT WALKING IN MY SHOES

(A rare case of hysterical conversion disorder)

Therapy in Action


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Case Three: SLOW MOTION SALLY

Therapy in Action


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Clients evaluation of alliance are better predictors of

outcome than therapists There is no correlation between length of treatment

and the strength of the alliance

Alliance is predictive of outcome across different

types of therapy and is even predictive of outcome inpsychopharmacotherapy

Common Factors


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Researchers are setting aside evidence based practice

in which the emphasis is placed on the treatmentitself, in favor of practice based evidence

This means not only gathering data on how therapy isworking for a particular client and therapist pairing

but then providing feedback to the therapist aboutthe clients improvement

Common Therapy


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For most disorders of adults and children, all

treatments intended to be therapeutic are equallyeffective

Must be cogent treatments provided by a clinicianwho believes in the treatment and accepted by the

client

Common Factors


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Some therapists are more effective than other

therapists regardless of the type of therapyadministered

Therapists who generally form better alliances havebetter outcomes

Alliance is dependent on the delivery of a particulartreatment

Common Factors


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Myth and Ritual

myth is the rationale for the treatment and theexplanation for the clients difficulties. The myth neednot be based on scientific truth. What is important isthat the myth must be accepted by the client and lead

to adaptive responses The ritual is the therapeutic actions, the process of

therapy

Common Factors


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Feedback to the therapists about their clientsprogress has been shown to improve outcome

Treatment models are important in that they are thevehicles through which common factors operate

The client more so than the therapist or the techniqueis what makes therapy work

The clients ability to use whatever is offered surpassand differences that might exist in techniques or

approaches

Common Factors


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Clients select from therapy what they need to get

better The quality of the clients participation is the most

important determinant of outcome

Common Factors


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What client factors are important?

Client cooperation versus resistance Client experience of the therapeutic bond

Clients contribution to the bond

Client interactive collabloration

Client expressiveness

Client affirmation of the therapist

Client openness versus defensiveness

Common Factors


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What therapist factors contribute to effectiveness

listen to clients-listen for their preferences andexperiences. Their voices tell us how to cultivate thetherapeutic relationship

Privilege the clients experience-understand and

privilege the clients theory and experience of change,not the therapists

Common Factors


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What therapist factors contribute to effectiveness

Request feedback on the therapy relationship-thisempowers clients, makes collaboration explicit andallows for mid-therapy adjustments as needed

Ask what has been most helpful in this therapy-you

will be amazed at the centrality of the therapeuticrelationship

Common Factors


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THE END

family therapy 101

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