Family therapy

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Definition

Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family. It may be conducted by a pair of therapists—often a man and a woman—to treat gender-related issues or serve as role models for family members. Although some types of family therapy are based on behavioral or psychodynamic principles, the most widespread form is based on family systems theory, an approach that regards the entire family as the unit of treatment, and emphasizes such factors as relationships and communication patterns rather than traits or symptoms in individual members.

Purpose

The purpose of family therapy is to identify and treat family problems that cause dysfunction. Therapy focuses on improvement in specific areas of functioning for each member, including communication and problem-solving skills.

Family therapy is often recommended when:

A family member has schizophrenia or suffers from another severe psychosis ; the goal in these cases is to help other family members understand the disorder and adjust to the psychological changes that may be occurring in the patient.
Problems cross generational boundaries, such as when parents share a home with grandparents, or children are being raised by grandparents.
Families deviate from social norms (unmarried parents, gay couples rearing children, etc.). These families may or may not have internal problems, but could be troubled by societal attitudes.
Members come from mixed racial, cultural, or religious backgrounds.
One member is being scapegoated, or their treatment in individual therapy is being undermined.
The identified patient's problems seem inextricably tied to problems with other family members.
A blended (i.e. step-) family is having adjustment difficulties.

Precautions

Before family therapy begins, family members are required to undergo a comprehensive clinical evaluation (interview) that includes questions of a personal and sensitive nature. Honest communication between the family members and the therapist is essential; people who are not willing to to discuss and change behaviors may not benefit from therapy.

Families that may not be considered suitable candidates for family therapy include those in which:

One or both parents is psychotic or has been diagnosed with antisocial or paranoid personality disorder.
Cultural or religious values are opposed to, or suspicious of, psychotherapy.
Some family members cannot participate in treatment sessions because of illness or other physical limitations.
Individuals have very rigid personality structures and might be at risk for an emotional or psychological crisis.
Members cannot or will not be able to meet regularly for treatment.
The family is unstable or on the verge of break-up.

Intensive family therapy may be difficult for psychotic family members.

Description

Family therapy is a relatively recent development in psychotherapy. It began shortly after World War II, when doctors who were treating schizophrenic patients noticed that the patients' families communicated in disturbed ways. The doctors also found that patients' symptoms rose or fell according to the level of tension between their parents. These observations led to considering a family as an organism (or system) with its own internal rules, patterns of functioning, and tendency to resist change. When the therapists began to treat the families as whole units instead of focusing solely on the hospitalized member, they found that in many cases the schizophrenic family member improved. (This does not mean that schizophrenia is caused by family problems, although they may aggravate its symptoms.) This approach was then applied to families with problems other than schizophrenia. Family therapy is becoming an increasingly common form of treatment as changes in American society are reflected in family structures; it is also helpful when a child or other family member develops a serious physical illness.

Family therapy tends to be short term, usually several months in length, aimed at resolving specific problems such as eating disorders, difficulties with school, or adjustments to bereavement or geographical relocation. It is not normally used for long-term or intensive restructuring of severely dysfunctional families.

In therapy sessions, all members of the family and both therapists (if there is more than one) are present. The therapists try to analyze communication and interaction between all members of the family; they do not side with specific members, although they may make occasional comments to help members become more conscious of patterns previously taken for granted. Therapists who work as a team also model new behaviors through their interactions with each other.

Family therapy is based on systems theory, which sees the family as a living organism that is more than the sum of its individual members and evaluates family members in terms of their position or role within the system. Problems are treated by changing the way the system works rather than trying to "fix" a specific member.

Family systems theory is based on several major concepts:

The identified patient

The identified patient (IP) is the family member with the symptom that has brought the family into treatment. The concept of the IP is used to keep the family from scapegoating the IP or using him or her as a way of avoiding problems in the rest of the system.

Homeostasis

This concept presumes that the family system seeks to maintain its customary organization and functioning over time. It tends to resist change. The family therapist can use homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change.

The extended family field

The extended family field is the nuclear family plus the network of grandparents and other members of the extended family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviors, and other issues.

Differentiation

Differentiation refers to each family member's ability to maintain his or her own sense of self while remaining emotionally connected to the family; this is the mark of a healthy family.

Triangular relationships

Family systems theory maintains that emotional difficulties in families are usually triangular—whenever any two persons have problems with each other, they will "triangle in" a third member to stabilize their own relationship. These triangles usually interlock in a way that maintains homeostasis. Common family triangles include a child and its parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.

Preparation

Families are often referred to a specialist by a pediatrician or other primary care provider. (Some estimates suggest that as many as 50% of pediatric office visits concern developmental problems in children that are affecting their families.) Physicians may use symptom checklists or psychological screeners to assess a family's need for therapy.

Family therapists can be psychiatrists, clinical psychologists, or other professionals certified by a specialty board in marriage and family therapy. They will usually evaluate a family for treatment by scheduling a series of interviews with members of the immediate family, including young children, as well as significant or symptomatic members of the extended family. This allows the therapist(s) to learn how each family member sees the problem and provides a first impression of the family's functioning. Therapists typically evaluate the level and types of emotions expressed, patterns of dominance and submission, roles played by family members, communication styles, and the existence of emotional triangles. They also note whether these patterns are rigid or relatively flexible.

Preparation also usually includes creating a genogram, a diagram that depicts significant persons and events in the family's history. They include annotations about the medical history and major personality traits of each member and help uncover intergenerational patterns of behavior, marriage choices, family alliances and conflicts, the existence of family secrets, and other information that sheds light on the family's present situation.

Risks

There are no major risks involved in receiving family therapy, especially if family members seek the therapy with honesty, openness, and a willingness to change. Changes that result from the therapy may be seen by some as "risks"—the possible unsettling of rigid personality defenses in individuals, or the unsettling of couple relationships that had been fragile before the beginning of therapy, for example.

Normal results

The goal of therapy is the identification and resolution of the problem that is causing the family's unhealthy interactions. Results vary, but in good circumstances they include greater insight, increased differentiation of individual family members, improved communication within the family, and loosening of previously automatic behavior patterns.

Resources

BOOKS

Clark, R. Barkley. "Psychosocial Aspects of Pediatrics & Psychiatric Disorders: Psychosocial Assessment of Children & Families." In Current Pediatric Diagnosis & Treatment , edited by William W. Hay Jr. and others. Stamford: Appleton and Lange, 1997.

Friedman, Edwin H. Generation to Generation: Family Process in Church and Synagogue. New York: The Guilford Press, 1985.

Glick, Robert Alan, and Henry I. Spitz. "Common Approaches to Psychotherapy: Family Therapy." In The Columbia University College of Physicians and Surgeons Complete Home Guide to Mental Health , edited by Frederic I. Kass, and others. New York: Henry Holt and Co., 1992.

Meissner, W. W. "The Psychotherapies: Individual, Family, and Group." In The New Harvard Guide to Psychiatry , edited by Armand M. Nicholi Jr. Cambridge, MA: The Belknap Press of Harvard University Press, 1988.

Noble, John, M.D. Textbook of Primary Care Medicine. St. Louis: Mosby, Inc. 2001.

PERIODICALS

Burge, S. K. "Behavioral Medicine in Family Practice: Behavioral Science in Family Medicine—What Evidence?" Clinics in Family Practice 3, no. 1 (March 2001).

Campbell, T. L. "Behavioral Medicine in Family Practice: Family Systems in Family Medicine." Clinics in Family Practice 3, no. 1 (March 2001).

Rebecca J. Frey, Ph.D.