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Family Therapy

Definition

Family therapy is a form of psychotherapy that treats all the members of a nuclear or extended family. It may be conducted by one therapist or by a pair or team. Some forms of family therapy are based on behavioral or psychodynamic principles; however, the most widespread form is based on family systems theory. This approach regards the family as a whole as the unit of treatment, and emphasizes such factors as role assignments, group dynamics, and communication patterns among family members rather than psychiatric symptoms in individuals.

Family therapy is a relatively recent development in psychotherapy. It began shortly after World War II, when psychiatrists who had been trained according to Freud's theories began to question the adequacy of Freud's account of emotional distress. Freud had proposed that psychological problems grew out of neurotic conflicts within the individual combined with destructive relationships in the family of origin, and that therapy would be most effective with the patient isolated from his or her relatives. The therapists who pioneered family therapy in the 1950s maintained instead that emotional problems developed and persisted within the context of the family. By shifting the emphasis from the inner world of the individual to his or her role in the family, these therapists were able to help family members change the circular or repetitive patterns of interaction that reinforced the family's problems.

In the early 2000s, family therapy is becoming an increasingly common form of treatment as such changes in American society as cohabitation, frequent divorce, and same-sex couples are reflected in family structures. In addition, managed care organizations are more likely to reimburse members for family treatment than for individual psychotherapy.

Purpose

Family therapy is often recommended in the following situations:

• Treatment of a family member with schizophrenia or multiple personality disorder (MPD). Family therapy helps other family members understand their relative's disorder and adjust to the psychological changes that may be occurring in the relative.
• Families with cross-generational problems. These would include problems caused by parents sharing housing with grandparents, or children being reared by grandparents.
• Families that deviate from social norms (cohabiting couples, gay couples rearing children, etc.). These families may not have internal problems but may be troubled by judgmental social attitudes.
• Families with members from a mixture of racial, cultural, or religious backgrounds.
• Families who are scapegoating a member or undermining the treatment of a member in individual therapy.
• Blended families with adjustment difficulties.

Precautions

Most family therapists presuppose average levels of intelligence and education on the part of adult members of the family.

Some families, however, are not considered suitable candidates for family therapy. They include:

• Families in which one or both of the parents is psychotic or has been diagnosed with antisocial or paranoid personality disorder.
• Families whose cultural or religious values are opposed to or suspicious of psychotherapy.
• Families with members who cannot participate in treatment sessions because of physical illness or similar limitations.
• Families with members with very rigid personality structures.
• Families that are unstable or on the verge of breaking up.

Description

Basic features of family therapy

Family therapy is usually short-term treatment, usually several months in length, with a focus on resolving such specific problems as eating disorders, difficulties with school, or adjustments to bereavement or geographical relocation. It is not intended for intensive restructuring of severely dysfunctional families.

In family therapy sessions, usually held once a week, all members of the family and both therapists (if there is more than one) are present. The therapists seek to analyze the process of family interaction and communication as a whole; they do not take sides with specific members. They may make occasional comments or remarks intended to help family members become more conscious of patterns that had been previously taken for granted. Family therapists who work as a team also model new behaviors for the family through their interactions with each other during sessions.

Family systems theory

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

• Identified patient (IP). The identified patient is the family member with the symptom that has brought the family into treatment. The concept of the IP is used by family therapists to keep the family from using him or her as a way of avoiding problems in the rest of the system.
• Homeostasis. The concept of homeostasis means that the family system seeks to maintain its customary organization and functioning over time. It tends to resist change. The family therapist can use the concept of homeostasis to explain why the family's 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.
• Extended family field. The extended family field refers to 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, communication patterns, and other behaviors.
• Differentiation. Differentiation refers to the ability of each family member to maintain his or her own sense of self, while remaining emotionally connected to the family. One mark of a healthy family is its ability to allow members to differentiate while feeling that they are "members in good standing" of the family.
• Triangular relationships. Family systems theory maintains that emotional relationships in families are usually triangular; that whenever any two persons in the family system have problems with each other, they will "triangle in" a third member as a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that maintains family homeostasis. Common family triangles include a child and its parents; two children and one parent; a parent, a child, and a grandparent; three siblings; husband, wife, and an in-law.

Preparation

Family therapists usually evaluate a family prior to treatment by scheduling a series of interviews with the members of the immediate family and significant or symptomatic members of the extended family. This process allows the therapist(s) to find out how each member of the family sees the problem, as well as forming first impressions of the family's functioning. Family therapists typically look for the level and types of emotions expressed, patterns of dominance and submission, the roles played by family members, communication styles, and the locations of emotional triangles. They will also note whether these patterns are rigid or relatively flexible.

Preparation for treatment also usually includes drawing a genogram, which is a diagram that depicts the persons and significant events in the family's history. Genograms help in uncovering 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.

Complications

The chief risk in family therapy is the possible unsettling of rigid personality defenses in individuals or of couple relationships that had been fragile before the beginning of therapy.

Results

Normal results include greater insight, increased differentiation of individual family members, improved communication within the family, loosening of previously automatic behavior patterns, and resolution of the problem that led the family to seek treatment.

Health care team roles

Families are often referred to family therapists by primary care physicians, pediatricians, or child psychiatrists. Family therapists themselves may be psychiatrists, clinical psychologists, clergy, social workers, or other professionals certified by a specialty board in marriage and family therapy. To qualify for certification, the professional must complete a master's or doctoral degree (either a Psy.D. or Ph.D.) in marriage and family therapy in addition to supervised clinical experience. As of 2005, 48 states and one Canadian province also require a state or provincial license to practice.

Resources

BOOKS

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

Glick, Robert Alan, MD, and Henry I. Spitz, MD. "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, MD, et al. New York: Henry Holt and Company, 1992.

Napier, Augustus Y., PhD, with Carl A. Whitaker, MD. The Family Crucible. New York: Harper & Row, Publishers, 1988. This case study, written by two of the pioneers in family therapy, has become a classic in the field of family therapy.

Nichols, Michael P., with Richard C. Schwartz. The Essentials of Family Therapy. Boston, MA: Allyn and Bacon, 2001.

PERIODICALS

Berman, E., and A. M. Heru. "Family Systems Training in Psychiatric Residencies." Family Process 44 (September 2005): 321-335.

Hoagland, K. E. "Family-Based Services in Children's Mental Health: A Research Review and Synthesis." Journal of Child Psychology and Psychiatry 46 (July 2005): 690-713.

Kaplan, L., and S. Small. "Multiracial Recruitment in the Field of Family Therapy: An Innovative Training Program for People of Color." Family Process 44 (September 2005): 249-265.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry (AACAP). 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891.

American Association for Marriage and Family Therapy (AAMFT). 112 South Alfred Street, Alexandria, VA 22314. (703) 838-9808. Fax: (703) 838-9805. 〈http://www.aamft.org〉.

American Family Therapy Academy (AFTA). 1608 20th Street NW, 4th Floor, Washington, DC 20009. (202) 483-8001. Fax: (202) 483-8002. 〈http://www.afta.org〉.

OTHER

"Psychotherapies for Children and Adolescents." AACAP Facts for Families #86. Washington, DC: AACAP, 2003.