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Family therapy

(Redirected from Family systems therapy)

Family therapy (or family systems therapy) is a branch of psychotherapy that treats family problems. Family therapists consider the family as a system of interacting members; as such, the problems in the family are seen to arise as an emergent property of the interactions in the system, rather than be ascribed exclusively to the "faults" or psychological problems of individual members.

A family therapist usually sees several members of the family at the same time in therapy sessions ("conjoint family therapy", this term is also used in the approach of Virginia Satir.) This setting has the advantage of making differences between the ways different family members perceive mutual relations as well as interaction patterns in the session apparent both for the therapist and the family. These patterns frequently mirror habitual interaction patterns at home, even though now the therapist himself is incorporated into the family system. Therapy interventions usually focus on these patterns of interaction rather than on analyzing subconscious impulses or early childhood traumas of individuals as a Freudian therapist would do.

Depending on circumstances, the therapist may then point out to the family these interaction patterns that the family might have not noticed; or suggest to individuals a different way of responding to other family members. These changes in the way of responding may then trigger repercussions in the whole system, leading sometimes to a more satisfactory system state.

Some key developers of theories of family therapy are:

  • Nathan Ackerman (psychoanalytic)
  • Walter Kempler (gestalt)
  • Murray Bowen (systems)
  • Salvadore Minuchin (structural)
  • James Framo (object-relations)
  • Jay Haley (communications)

Nathan Ackerman began as a psychoanalytic therapist, and his training is evident in his formulations of the nature of family dysfunction and the path towards change. Psychoanalytic training itself does not lead to a focus on family process, however; Ackerman describes himself as a “maverick” who was influenced by Harry_Stack_Sullivan and by social science, which broadened his intra-psychic orientation to include interpersonal and social considerations.

For Ackerman, a healthy family exhibits a “homeodynamic principle”, a term that combines the opposite notions of homeostasis and change. Homeostatic balance refers to a complimentarity in the roles and relationships of the family members that allows for structure and stability rather than uncertainty and family chaos. This homeostasis is dynamic in the sense that it is adaptive in nature, changing as the family ages (causing a role reversal) and as new situations arise for the family to adapt to. The dysfunctional family is not adaptive; its rigidity leads to isolation or emotionally distant members, factions, demoralization, and the inability to fulfill various family functions. While this failure to fulfill family functions may be seen in the presenting problems, such as learning disabilities, acting out, parental abuse, etc, Ackerman defines a symptom either as “a unit of relational adaptation that is irrational, inappropriate, automatized, and repetitive” or as pathologically loose, rapidly changing role relationships that lead by stages to the disintegration of the family”. The sources of these pathological states are the defenses used by individual family members, which create the transactional symptoms described above.

Given this formulation, it is not surprising that the therapist intervenes on the level of conceptulization and interpretation. Ackerman is highly active during sessions, noting, exposing and interpreting defenses, so as to neutralize imbalances and scapegoating, and to point out the effects of such symptoms on the emotional health of the family members. As with “making the unconscious conscious,” the purpose of exposing defenses is to create change by upsetting a heretofore automatic set of reactions, to imbalance dysfunctional homeostasis and allow it to be examined rationally and thereby change to a new, more functional level of homeostasis. Change itself comes about by the promotion of improved reality testing, heightened levels of awareness, leading to freer and more open communication and improved problem-solving techniques among the family members.

Psychoanalytic training was also the starting point for Walter Kempler ; he later became interested in existential issues and family therapy. He worked for a time with Fritz Perls, and there is much overlap in their orientations.

Walter Kempler calls his form of treatment, variously, Experiential or Gestalt family therapy. His focus is on the immediate, on feelings and desires that lie behind verbal and nonverbal messages, and on their clear and complete delivery. Full engagement of family members is his immediate goal, which in turn supports his overall goal, the experience of life, its ongoing flow of union and separation. “Neither separateness nor union is the goal of the therapeutic process, but rather the exhortation of the endless and often painful undulation between them”. A family is made up of members who need and seek both union and separation from each other. The task of the therapist is to reconcile emerging and often conflicting personal desires, to “arouse (remind) forgotten desires; to fire up abandoned conflict; and to keep all combatants at the front until everybody wins”. Winning, of course, does not mean that everybody is satisfied with the result, but rather, the resulting satisfaction, compromise, or loss, is fully felt, with no residuals; for example, if someone must give up a cherished fantasy about their relationship, this loss must not only be realized, but experienced and fully grieved.

Experience is essential for Kempler. He sees his approach as “oriented to an exploration of the resistances to experience”. He is quite clear in asserting that experience, action, is the key to producing change. The therapist can lead or push people toward experience, but wherever possible must not usurp the experiencing, but let the momentum created carry the participants into the intimate experience of each other, and their own desires, needs and fantasies. “Desire, clearly expressed and movingly delivered, brings change in its wake, sometimes through fulfillment, sometimes through the expression alone”. For Kempler, change results from confronting and fully experiencing reality in the here and now, leading to the acceptance of one’s, and other’s, continual movement toward and away from union.

As have other family therapy theorists, Salvador Minuchin has developed his own form of family therapy; his includes not only a unique terminology, but also a means of depicting key family parameters diagrammatically. His focus is on the structure of the family, including its various substructures. In this regard he is a follower of systems and communication theory, since his structures are defined by transactions among interrelated systems within the family. He subscribes to the systems notions of wholeness and equifinality, both of which are critical to his notion of change.

According to Minuchin, a family is functional or dysfunctional based upon its ability to adapt to various stressors (extra-familial, idiosyncratic, developmental), which in turn rests upon the clarity and appropriateness of its subsystem boundaries. Boundaries are characterized along a continuum from enmeshment through semi-diffuse permeability to rigidity. In addition, family subsystems are characterized by a hierarchy of power, typically with the parental subsystem “on top” vis-à-vis the offspring subsystem. In healthy families, parent-children boundaries are both clear and semi-diffuse, allowing the parents to interact together with some degree of authority in negotiating between themselves the methods and goals of parenting; from the children’s side the parents are sufficiently unemeshed from the children to allow for the degree of autonomous sibling and peer interactions that produce socialization, yet not so rigid or aloof as to ignore childhood needs for support, nurturance and guidance. Dysfunctional families exhibit mixed subsystems (i.e, coalitions) and improper power hierarchies, as for example when a older child is brought in to the parental subsystem to replace a physically or emotionally absent spouse.

Minuchin’s goal is to promote a restructuring of the family system along more healthy lines, which he does by entering the various family subsystems, “continually causing upheavals by intervening in ways that will produce unstable situations which require change and the restructuring of family organization…. Therapeutic change cannot occur unless some pre-existing frames of reference are modified, flexibility introduced and new ways of functioning developed”. To accelerate such change, Minuchin manipulates the format of the therapy sessions, structuring desired subsystems by isolating them from the remainder of the family, either by the use of space and positioning (seating) within the room, or by having non-members of the desired substructure leave the room (but stay involved by viewing from behind a one-way mirror). He believes that change must be gradual and taken in digestible steps for it to be useful and lasting. Because structures tend to self-perpetuate, especially when there is positive feedback, Minuchin asserts that therapeutic change is likely to be maintained beyond the limits of the therapy session.

One variant or extension of his methodology can be said to move from manipulation of experience toward fostering understanding. When working with families who are not introspective and are oriented toward concrete thinking, Minuchin will use the subsystem isolation—one-way mirror technique to teach those family members on the viewing side of the mirror to move from being an enmeshed participant to being an evaluation observer. He does this by joining them in the viewing room and pointing out the patterns of transaction occurring on the other side of the mirror. While Minuchin doesn’t formally integrate this extension into his view of therapeutic change, it seems that he is requiring a minimal level of insight or understanding for his subsystem restructuring efforts to “take” and to allow for the resultant positive feedback among the subsystems to induce stability and resistance to change.

Change, then, occurs in the subsystem level and is the result of manipulations by the therapist of the existing subsystems, and is maintained by its greater functionality and resulting changed frames of reference and positive feedback.

James Framo ’s work, family transactional therapy, is grounded theoretically in Fairbairn’s theory of object-relations. In a sentence, Framo sees family dysfunction as the projection of early introjected objects onto current spouses and children. Thus, symptoms occur in the family and in family transactions, rather than strictly within individual members of the family, and must be understood as a combination of both individual and transpersonal aspects of the personality. The powerful internal object world, in its effort to master old conflicts, produces unconscious attempts to recreate itself in the real world using the family members as its props. Framo rejects systems theory as a complete explanation of critical family transactions, noting that “one cannot wipe out entirely the realm of inner experience as irrelevant to family systems theory; inner experiences both mediate and are mediated by systems phenomena”. Therefore, for Framo the heart of family therapy involves uncovering the distorted internal part-objects carried by the family members, with particular attention paid to the parents’ internalizations and projections. “The essence of the true work of family therapy is in tracing the vicissitudes of early object-relations … which occur as a function of the intrapsychic and transactional blending of the old and the new family systems”.

Inexplicably, yet probably accurately, Framo reports not only that in the course of therapy sessions he uses methods from a wide range of orientations, but also that, when observing other experienced therapists work, he notes that they all tend to act remarkable similarly regardless of their orientation. Thus, one is hard-pressed to determine what, for Framo, constitutes the nature of change. He clearly believes that individuals in family therapy must work through the struggle with their internal objects, with the major resistance being their libidinal attachment to their parental introjects, but it is uncertain how he works to uncover and, more to the point, have the members work through, their projections. From his comment on his eclectic style, quoted above, one can assume that he uses a combination of insight-fostering methods, using transference feelings and resistances, as well as insight-independent behavior changing methods, such as paradoxical instructions. Thus, his theoretical stance aside, one might say that he squeezes whatever he can from what is available intrapsychically and interpersonally, with the goal of exposing introjects, but using te more immediate tool of pointing out and stopping dysfunctional behaviors at the surface level. He feels that few families reach the level of dealing with their introjects, and in actual treatment he himself rarely works on that level. It seems as if he would like to see deep intrapsychic change occur, but will settle for the replacement of dysfunctional patterns with those coming from more reality-based expectations, even in the absence of their deep understanding of the source of their unreal expectations and reactions. Thus, it could be said that for Framo, the nature of change is whatever will work to produce improved behavior, although theoretically he seeks to uncover projections, by attending to the family transactions, and having the family members work through them.

Jay Haley is a creative, provocative clinician who seems to delight in making definitive, challenging statements. Perhaps, then, it is no coincidence that his method of therapy-–he claims not to have a theory of therapy—-emphasizes creative and provocative instructions for the clients to react to.

Haley adheres to a systems/communications model of family interaction, and in fact restricts himself to dealing specifically with the interactions, the repeated sequences of behaviors, and has little interest in such areas as insight, catharsis, or other concepts not directly tied to overt behavior. Haley sees dysfunctional communications as paradoxical, in that their content is not congruent with their metacommunication. His therapeutic goal is to stop problematic behavior sequences and replace them with more functional, flexible ones. Haley believes that feelings will change as a result of behavior changing, and thus need not be dealt with directly. He tends to formulate the issue, for the clients, in terms of solving the problem that brought them into therapy, while keeping within himself a more sophisticated formulation focused on patterns of repeated interactions, dysfunctionally inflexible and often involving issues of control over the creating and enforcement of family rules. The therapist’s role is to intervene in whatever ways will effectively and efficiently bring about changes in the family’s hierarchy and interactive patterns, to promote congruence in communications and family rules. He uses a variety of techniques, all intended to change the behavior of the system rapidly, with or without awareness. Typical of his interventions are metaphorical statements, purposely kept at what might be called a subliminal level, alluding to the type of change desired by the therapist, and the introduction of a paradoxical injunction intended to restructure the system (e.g., by having a relatively alienated couple work together in trying to deal with the therapist’s bizarre prescriptions).

Successful therapy is the successful solution to specific problems, achieved through an increase in the variety, complexity, and congruence of the family members’ responses. For Haley, change within an organization produces change within individuals. By forcing a change in interactional patterns, new patterns, and with them new hierarchies and coalitions, emerge; those changes require individuals to respond in new ways, to develop new patterns of response. Haley does not distinguish between a “changed” individual and an individual simply emitting new behaviors in response to a new environment. Whether the individual would respond in old ways if the rest of the family “regressed” to an old pattern is left unanswered; the system has changed in the direction of functionality, alleviating the presenting problem(s); individuals, in this new setting, are reacting with different patterns, and thus, for Haley, they are changed.

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