Family Therapy Research Paper

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Family therapy is a treatment approach that takes the family unit as its focus. Family therapists understand the emotional and behavioral problems of individuals as often being related to problems in the family systems of which they are part. They believe that by working to promote change in the family, the symptoms and problems of the family’s members will be resolved, or at least ameliorated. Sometimes, but less often, it is the family as a group that presents with problems. An important feature of the family therapy approach is an emphasis on the concept of circular, rather than linear causation. Family therapists are reluctant to regard events or behaviors in families as due to single, isolated causes, but tend to see them as parts of, usually complex, chains of events.

Outline

I. The Development of Family Therapy

II. Theoretical Concepts

A. Systems Theory

B. Learning Theory

C. Communications Theory

D. Family Structure

E. Family Development

III. Schools of Family Therapy

A. Structural Family Therapy

B. Approaches Using Communications Theory

C. Behavioral Family Therapy

D. Extended Family Systems Therapy

E. Experiential Family Therapy

F. Psychodynamic Family Therapy

G. Strategic Family Therapy

IV. Assessing Families

A. Task Accomplishment

B. Role Performance

C. Communication, Including Affective Expression

D. Affective Involvement

E. Control

F. Values and Norms

V. Helping Families Change

A. Direct Interventions or Injunctions

B. Indirect Interventions or Injunctions

I. The Development of Family Therapy

The family therapy approach to the treatment of mental health problems was developed during the years that followed the Second World War. Psychotherapists of various mental health disciplines, together with researchers from other disciplines, began to look at their patients’ families as possibly contributing to the disorders they were treating. The idea that families might have a part in the genesis of psychiatric disorders was not new. Freud and others from the early days of psychoanalysis had postulated that the early childhood family relationships of their patients had caused the neurosis with which these patients presented. In those early days, however, the response was to separate the patients from their families for treatment. This was accomplished either by seeing patients for treatment on their own while having minimal or no contact with their families; or by admitting them to psychiatric hospitals or other institutions where they could be cared for and treated away from the supposed adverse influences of their families. What was new was the idea that it was possible to work with families, in the here and now, to change their ways of functioning; and that this might be a quicker and more effective approach than individual psychotherapy with individual patients.

One of the first to point out the importance of the family was Christian Midelfort whose book, The Family in Psychotherapy, was published in 1957. Despite its promising title, however, this was not truly a book about family therapy. More important was Nathan Ackerman’s The Psychodynamics of Family Life, published the following year. Like many of the pioneers of family therapy, Ackerman came from a background of psychoanalytic training, and his first book reflects this. But he pointed out that while psychiatrists had become adept in the retrospective study of mental illness and in the careful examination of family histories, they had not yet cultivated an equivalent skill in the study of current family processes. Ackerman went on to suggest that, by acquiring skills in working with whole family groups, we would add a new dimension to our understanding of mental illness as an ongoing process—and one that changes with time and the conditions of group adaptation.

By 1966 Ackerman’s thinking had developed further and his second book, Treating the Troubled Family, was probably the first true single-author family therapy book published. By the mid-1960s many groups, several of which had commenced their studies and treatment of families in the 1950s, were publishing their findings. Among the other early pioneers in family therapy were Murray Bowen, Don Jackson, John Elderkin Bell, Don Jackson, Jay Haley, John Weakland, Virginia Satir, Lyman Wynn, Salvador Minuchin and Ivan Boszormenyi-Nagy. Each therapist, or group of therapists, developed a particular approach and theoretical framework. While these often differed substantially, they had in common their focus on the family group and how it functioned. The enthusiasm of some of these pioneers was unbounded, and extreme claims for the effectiveness, or at least the potential, for family therapy were sometimes made. All, or almost all, psychiatric problems came to be seen by some as residing, not in individuals, but in the processes of interaction going on in the person’s family or other social group or groups.

Over the years, most of these extreme views have become modified. Family therapy has come to be regarded as a useful therapeutic option and the treatment of choice in many cases. But it is not a cure-all and it may need to be used along with other treatments. The almost religious zeal of some of the early pioneers has been toned down by the harsh reality of clinical experience and the results of research. Many of the pioneers paid particular attention to patients with schizophrenia, the origins of which, they believed, lay in the family. However the failure of family therapy to prove effective as a primary treatment, combined with increasing knowledge of the neurochemical and biological correlates of the condition and the greater effectiveness of pharmacological treatments, has resulted in a shift of focus toward other disorders. Nevertheless, more recent research has shown that family factors are by no means irrelevant in schizophrenia, and may determine whether relapse occurs after patients return home following treatment in hospital.

II. Theoretical Concepts

A. Systems Theory

A way of thinking about families that was seized on early in the development of family therapy was that of general systems theory. This theory, originally developed in the 1950s, is concerned with how parts are organized into wholes. Although it was not designed with families in mind, systems theory was found to fit in well with the thinking of many of the early family therapists. The idea that families are open systems has continued to be central to the work of virtually all family therapists. The task of the systems-based therapist thus becomes that of first determining how the family system is functioning, and then facilitating any changes that appear to be required in the way it functions. The systems-oriented therapist expects that once the needed changes in family functioning have been achieved, the symptoms of the member(s) who have been experiencing difficulties will be resolved, or at least ameliorated.

What exactly are the basic principles of systems theory that family therapists have found useful? In summary, they are that:

• Families, and other social groups, are systems that have properties that are more than the sum of the properties of their parts.
• Certain general rules govern the functioning of such systems.
• Every system has a boundary. The boundaries of family systems are permeable in varying degrees, so that some families are more readily, and to a greater extent, influenced by what is going on around them than are others.
• Family systems typically reach relatively steady states; that is, each family settles down to function in its own characteristic way, although change can occur; indeed growth and evolution are usual as the composition of the family changes, its members age, and changes occur in the wider systems of which it is a part.
• The amount and quality of the communications between the parts of the system, are important features.
• The concept of circular causality is preferred to that of linear causality.
• Family systems, like other systems, appear to be purposeful. They serve such purposes as the rearing of children; the provision of mutual comfort and a context for the expression of the marital partners’ sexuality; and the promotion of the economic security of the family group.
• Systems are made up of subsystems and are parts of larger suprasystems.

Many individuals and families come to therapists asking to be told the ‘‘cause’’ of the problem that is concerning them. They tend to see causality in linear terms. An example of linear causality is the action of a man who puts up his umbrella when it starts to rain. The cause is clear—it is raining—and so is the result— up goes the umbrella. It is not usually believed that putting up the umbrella affects the weather. But in families things are seldom, if ever, that simple. If person A tells person B to do something, and B does it, this in turn will affect the behavior of A, who may, for example, be more likely to ask B to do the same task again when the need arises. There may also be similar, or perhaps opposite, effects on the behavior of other family members.

Let us consider a family in which there is a boy who is anxious about going to school. When it is time to leave for school, the boy cries, clings to his mother, and refuses to leave the house. The mother turns for help to her husband. He fails to give her support and even blames her for not being firm enough with the boy. Instead he speaks angrily to his son. This increases the boy’s anxiety and his tears flow even more freely. This leads to the mother becoming yet more worried and upset; she comforts the boy and then turns with even greater force to her husband who gets even more angry with the boy, and perhaps with the mother also. So whose problem is it? Is it the mother’s anxiety about her son that results in her being unable to support her son calmly in the task of separating from her to go to school? Or is the basic problem that of a boy who is (for whatever reasons) emotionally immature and constitutionally prone to react anxiously in situations perceived as threatening? Or is the real problem a dysfunctional parental or marital relationship? Or maybe the cause of it all is an angry, dominating, verbally abusive father? And so on. In other words, who or what is causing the problem? Considering this scenario, some might try to answer these questions in a straightforward way. The family therapist interested in circular causality, however, would not consider it useful to do so. All the problems implied in the questions might indeed exist but none is ‘‘the cause.’’ They are all simply—or perhaps not so simply—part of a circular process. To put it another way, they all reflect characteristics of the way the family systems works.

B. Learning Theory

Many other theoretical concepts are used by family therapists. Therapy, whether or not it is addressed to the family system, may be looked on as a teaching and learning process. When we are treating families there is nearly always a need for the family to learn such things as new ways of relating to each other; new approaches on the part of the parents to rearing their children; new ways of allocating the tasks the family members must, between them, ensure are done; perhaps a new type of marital relationship.

While few family therapists would regard themselves simply as teachers, and family therapy is much more than telling people what they should do, learning must happen during the treatment if change is to occur. Learning is conceptualized to occur in several ways:

1. In respondent conditioning, a behavior is learned when a rewarding stimulus is paired with a desired behavior. Pavlov’s much quoted dogs learned to associate the ringing of a bell with the presentation of food. After a while they salivated in response to the ringing of the bell, without the presentation of any food.
2. In operant conditioning the circumstances following a behavior are altered either to reinforce the behavior or to extinguish it. In other words it consists of the systematic, and, ideally, carefully planned, application of positive and negative responses (or, in everyday language, rewards and punishments).
3. Modeling is the process by which people acquire behaviors by imitating others. It need not be, and usually is not, a conscious process. Therapists can, and regularly do, model behaviors during their sessions with their clients. The respectful way the therapist addresses family members; how the therapist talks or plays with a child; or how the therapist reacts to things family members do or say—all these and many other behaviors carry messages.
4. Learning by cognition occurs when a person thinks something through and comes to a conclusion as a result. In lay terms, it is the process of ‘‘figuring things out.’’

All of these learning processes may occur during family therapy. The therapist must devise ways of tapping into the potential all people have to learn new behaviors, concepts, and ways of viewing things.

C. Communications Theory

The processes of communication within families are of great interest to family therapists. In many families with problems, communication is deficient in some way. It may be insufficient, unclear, indirect or contradictory, or the information communicated may be just incorrect. Also important is the process of communication between therapist and family. Much attention has therefore been given to communication theory by family therapists.

Therapists are concerned with syntax, the grammatical rules of a language; semantics, the meaning of words and how they are put together to convey meaning, including the clarity of language and how it is used in particular situations; and pragmatics, the study of the behavioral effects of communication. These latter effects are related as much to the nonverbal communications that go along with the words spoken, as to the words themselves. Indeed sometimes the nonverbal is the essence of the communication—a laugh, perhaps.

Many other aspects of communication have been studied by family therapists. Communications can define relationships; how we talk to our bosses may be very different than how we talk to our employees, our children, or our spouses. Also it is impossible, if one is in the presence of another person, not to communicate. Simply remaining silent, or looking away or busying oneself with someone or something else can carry powerful messages.

Family therapists are interested in whether communications between family members are symmetrical or complementary. In symmetrical communication the participants are on an equal footing. Complementary interaction occurs when the participants are not on an equal footing; examples would be many (but not necessarily all) doctor–patient, penitent–confessor, teacher–student, and master–servant interactions.
Two other types of communication merit mention here. One is the paradoxical statement. A simple example is the sentence, ‘‘I am lying.’’ Another would be, ‘‘I will call you when you least expect me to.’’ Related to this is the much written about ‘‘double-bind.’’ This is a rather more sophisticated way of giving contradictory messages simultaneously. The double-bind occurs when there are two people in an intense relationship. Two injunctions are given that are incompatible, but the person concerned feels a strong need to obey them both. The subject cannot discuss the conflict (in other words meta-communication—that is, communication about the communication—is not possible), and cannot escape from the situation. Cinderella was placed in a double-bind when her stepmother told her that of course she could go to the ball at the palace, but she must finish the work allocated to her before she could get ready. This was impossible in the time available and only the intervention of her fairy godmother and the latter’s magic spell enabled Cinderella to attend.

The double-bind has been frequently observed in the families of patients with schizophrenia, and in the early days of family therapy it was thought by some that it played a part in the causation of the condition. The idea was that, after repeated ‘‘double-bind’’ experiences over a long period of time, a person might be driven to forsake reality for a psychotic world. In due course, however, it was discovered that the double bind was common in many other families and it is no longer generally considered to be an important etiological factor in schizophrenia. Much the same applies to the concept of ‘‘communication deviance,’’ a form of aberrant communication described during the early studies of schizophrenic patients. More recently, evidence has emerged that ‘‘expressed emotion’’ is important. While a high level of expressed emotion in the family is not thought to be a cause of schizophrenia, it does seem that it may lead to relapse after treatment away from the family has been successful in producing a remission.

D. Family Structure

The concept of family structure, either overtly expressed or implied, is common to many schools of family therapy. It was well described by Salvador Minuchin in his 1974 book, Families and Family Therapy. It is related to systems theory concepts in that the perceived ‘‘structure’’ in a family system consists of the various subsystems in the family and the nature—that is strength and permeability—of the boundaries between them.

A typical, well-functioning family might have quite a simple structure: a parental subsystem and a child subsystem. In two-parent families some would distinguish the parent subsystem from the marital subsystem, since the way a couple relate as a marital pair is often distinct from how they function as parental couple. There might be expected to be a well-defined, but not overly rigid and impermeable boundary between the parental and the child subsystems.

The nature of the boundaries that exist between the subsystems in families is of great interest to the structural family therapist. Related to this are the concepts of enmeshment and disengagement. Enmeshment is said to exist when the boundaries between family members or subsystems are weak and readily permeable; it implies an overclose involvement of those concerned. When families members are enmeshed, their behaviors and, often, emotional states have marked effects on each other. In contrast to this, if members are disengaged, the behavior of one member will have little effect on those with whom the member is disengaged.

In a less well-functioning family one might find a different subsystem pattern. For example, there might be a subsystem consisting of the mother in an enmeshed relationship with one or two children, and another comprising the father. The boundary between the two subsystems might be robust, with little interaction or communication of feeling between them.

Many other family structures may be encountered; indeed the possibilities are limitless. In larger families there may be more than one child subsystem; for example, an older child subsystem and a younger child one, or male and female subsystems. And the structural problems may not be confined to the nuclear family. The extended family—grandparents, uncles, aunts, and other relatives—may be involved. So may friends, school staff and others, depending on the boundary between the family and its suprasystems.

E. Family Development

Families are not static entities. They change and develop. Among the considerations the therapist working with a family must take into account and is where the family is in its life cycle, for families have life cycles, just as individuals do. Moreover, many family problems prove to be associated with difficulties in proceeding from one stage of the life cycle to the next.

The family life cycle has been described and subdivided in a variety of ways. In summary, however, it is generally as follows. The starting point is arbitrary:

• The single adult person.
• Two single adults get together as a couple. Traditionally they get married, but in many societies nowadays a formal marriage ceremony is not required. This may be termed the childless couple stage.
• The couple have a child, often going on to have several more. We now have the couple with young children.
• The oldest child starts school. The family enters the stage of the couple with school-age children.
• The oldest child enters adolescence.
• The first child (it need not be the oldest) leaves home. This is the family launching its children into the wider world.
• The last child leaves home. This is the start of the ‘‘empty nest’’ stage.
• Retirement, aging, and grandparenthood.

The above is necessarily an oversimplification. Clearly, a family can be, and indeed will often be, in several stages at the same time. Some children may be in school while others have not started; some will have reached adolescence and others will not have. The parents may even have retired before all the children have left home. An additional complication is that many families do not follow the above course. We see, for example, family groups that have only contained one parent from the start; others disrupted by divorce or the death of one parent; blended families of various types; homosexual couples, with or without children; families in which it is the grandparents who are caring for the children.

What the family therapist must do, with every family that presents, is determine where the family is in its life cycle, and whether it is encountering any difficulty in moving from one stage to the next. It is often found that a family has functioned well at one stage, perhaps before the arrival of children, but does less well at the next, for example, when a third member, in that case a newborn child, is added. But any transition can present a challenge, as can single parenthood, blended family situations, and other special circumstances—for example, the incarceration of a family member.

The family therapist’s work becomes even more complex when families have become split up because of separation or divorce, an increasingly common scenario in many contemporary societies. The children’s time may be divided between the separated parents, whose conflicts and disagreements may persist despite the separation or divorce. Emotional problems, conflicts of loyalties, financial hardship and disputes, and custody and access issues may be sources of stress to all concerned. Often the children suffer most, and they sometimes come to play the role of pawns in ongoing ‘‘battles’’ between their parents. One or both parents may be in new relationships, which can complicate matters further.

In these situations the therapist may come to play the role of mediator, maintaining a neutral stance and being careful not to become overidentified with the point of view of any party. At the same time the wellbeing of all concerned, especially the children (who tend to be most at risk), must be the primary concern of the therapist. In these often unfortunate, even tragic, situations therapists may need to cast their nets wide and involve more than just the specific family grouping that has initially sought help—regardless of who is paying.

III. Schools of Family Therapy

Many different approaches have been, and continue to be, used by therapists in their efforts to promote change in families. As the field developed, most of the pioneers became identified with particular methods, and so ‘‘schools’’ of family therapy came to be identified. Nevertheless, there was, from the start, much overlap between the methods of different therapists and schools. It can also be difficult to know how far the success of a particular approach is due, on the one hand, to the theoretical underpinnings and the methods used and, on the other hand, to the personality and charisma of the therapist. Many of the pioneers were powerful personalities, with well-developed interpersonal skills and great powers of persuasion. Even today, the ability of therapists to establish rapport with the families they treat, and to be convincing in the interventions they offer, is probably at least as important as their theoretical persuasion or the school of therapy to which they subscribe. Subject to the above provisos, here are brief descriptions of some of the main schools of family therapy.

A. Structural Family Therapy

We have seen how this approach looks at the subsystem pattern within the family and the nature and strength of the boundaries between the subsystems. Structural therapists first assess the existing family structure and how this may be related to the problems the family is experiencing; and then they set out to assist the family in making the changes that seem to be needed. The following are considered:

• The arrangements, or unwritten ‘‘rules,’’ that govern the interactions between family members.
• The flexibility of the family’s way of functioning, and how easily it can change.
• The family’s ‘‘resonance.’’ This is the extent to which family members are enmeshed or disengaged.
• The family’s life context, that is, the relevant suprasystems.
• The family’s developmental stage.
• How the symptoms of the family member(s) who are presented for treatment fit into the family’s transactional patterns.

B. Approaches Using Communications Theory

Here the emphasis is on the patterns and styles of communication in the family. It was observed, from the earliest days of the family therapy movement, that families with symptomatic members often had major communication problems. These may involve:

• The cognitive understanding of what the members are saying to each other. What one member intends to convey to another is not correctly understood.
• The communication of feeling. It is often important, if a family is to function well without any members developing symptoms, for the members to be able to communicate effectively to each other how they feel.
• Communication and power. Jay Haley has eloquently pointed out that when one person communicates with another, that person is maneuvering to define a relationship. This probably does not apply to every communication. Some are simply intended to provide needed information, such as what time it is. Yet if one person has persistently to ask another one—the same other one—for the time this may say something about the relationship between the two.

Distinguishing one school of family therapy as particularly concerned with communication should not be taken to mean that therapists of other schools are not interested in family communication. It is merely a matter of emphasis. Indeed, Haley, who has been described as being of the ‘‘communication and power’’ school, also emphasizes the importance of establishing appropriate hierarchical arrangements within families— a concept that has much in common with structural therapy.

C. Behavioral Family Therapy

Therapists who take a behavioral approach lean heavily on learning theory. They understand the dysfunctional or deviant behaviors occurring in the families they treat as learned responses that can be replaced by more functional behaviors and ways of reacting by the use of behavioral techniques such as those outlined above. A prominent practitioner of and researcher in behavioral interventions with families is Gerald Patterson. Like most behaviorists he tends to be precise in his definition of problem behaviors, carrying out a careful analysis of what is happening—especially what appears to be maintaining the undesired behaviors— before devising interventions in the family system designed to produce behavioral change.

D. Extended Family Systems Therapy

The extended family systems approach is sometimes referred to as the ‘‘three generational approach.’’ Therapists of this school pay particular attention to the extended families of their patients. They are impressed by the way behaviors and ways of relating seem to be handed down from one generation to the next. They emphasize the role of the families of origin of the family members in influencing current family functioning; and they play close attention to the ongoing relationships the families they treat have with their extended families. Many of their therapeutic interventions take into account, or actually involve, the extended family.

Murray Bowen has often been included among the ranks of the ‘‘extended family systems’’ school, and rightly so, but his own theory differs from that of most others. He has maintained that many family problems arise because the family members have not differentiated themselves psychologically from their families of origin, a problem he saw himself having before he made a ‘‘voyage of discovery’’ to his family of origin. He also described the ‘‘undifferentiated ego mass,’’ later preferring the term ‘‘nuclear family emotional system.’’ A major aim of the therapist using Bowen’s theory is to assist family members in differentiating themselves from the ‘‘undifferentiated ego mass.’’ This, he asserts, enables them to function independently and autonomously, for example, as members of their own newly created families.

Whether there is a true school of extended family therapy may be questioned. Indeed it is probable that none of the schools we are discussing here exists in pure form. What we are describing are the points, the aspects of therapy, to which each school pays particular attention.

E. Experiential Family Therapy

Therapists who come under the ‘‘experiential’’ rubric tend to eschew theory. Instead, they join the family system and allow themselves to become involved in the intense interactions between the family members. Carl Whitaker and Walter Kempler are the best-known proponents of this approach. They do not offer us a consistent theory, but rather trust their instincts, or what Whitaker called, ‘‘The accumulated and organized residue of experience, plus the freedom to allow the relationship to happen, to be who you are with the minimum of anticipatory set and maximum responsiveness to authenticity and to our own growth impulses.’’ This school of therapy is probably best experienced; if you cannot do that, the next best thing is to read the writings of Whitaker, Kempler, and their ilk.

F. Psychodynamic Family Therapy

In a sense, this is a contradiction in terms, since family therapy is concerned with family systems, and not primarily with the psychopathology of family members. But many of the figures who played major roles in the early development of family therapy came to it from a psychoanalytic background. As far as there is such a thing as psychodynamic family therapy, it seems to be therapy that aims to help family members gain insight into themselves and how they react with each other.

Psychoanalytic thinking informed the early work of Nathan Ackerman, as well as that of Virginia Satir. However, Satir was a therapist of many parts who seemed to draw her ideas from a wide variety of sources.

G. Strategic Family Therapy

The ‘‘strategic’’ school of therapy is less well defined than some of the other schools. Cloe Madanes, in her 1981 book, Strategic Family Therapy, suggested that it is the ‘‘responsibility of the therapist to plan a strategy to solve the client’s problems.’’ She saw strategic therapy stemming from the work of Milton Erickson, who often used indirect means of promoting change in his patients. These means are discussed below in the section ‘‘Indirect Interventions and Injunctions.’’ A problem with the term ‘‘strategic therapy,’’ however, is that presumably every effective therapist uses strategies of some sort in attempting to assist families make the changes they seek. It is thus somewhat imprecise.

This brief overview comes nowhere near to covering all the schools of, or approaches to, family therapy. It is presented to make the point that there are many possible approaches to the task of helping families change.

IV. Assessing Families

Regardless of their theoretical orientation, all therapists must first come to an understanding of the changes in the family system that need to be made to resolve the problems that therapy is to address. This involves some sort of assessment, although how detailed it is varies from therapist to therapist. The experiential therapists probably emphasize assessment least. Therapists of most other schools have systematic ways of assessing families along a variety of parameters. As an example, we will consider the Process Model of Family Functioning, which resembles and was in part derived from McMaster Model of Family Functioning. This considers six aspects of family functioning:

A. Task Accomplishment

Task accomplishment is similar to the ‘‘problem solving’’ of the McMaster model. It involves:

• Identifying the tasks to be accomplished;
• Exploring what approaches might be used and selecting one;
• Taking action;
• Observing the results of the action and making any necessary adjustments.

Both models consider three categories of tasks: basic, developmental, and crisis. Basic tasks are such things as the provision of food, clothing, and shelter. Developmental tasks are those required as the family moves from one developmental stage to the next. Crisis tasks are those presented by such events as the death or serious illness of a family member, job loss, natural disaster, or migration from one culture or another.

B. Role Performance

In a well-functioning family each member has a role, or habitual pattern of behavior. Together, these ensure that everything that needs to be done is done, and each family member’s role is an appropriate one. In dysfunctional families it may be found that members, often those with symptoms, have assumed ‘‘idiosyncratic’’ roles, such as family scapegoat, ‘‘parental’’ child, sick member, or disturbed or ‘‘crazy’’ member.

C. Communication, Including Affective Expression

We have seen how important communication is in families, and what some of the main communication problems tend to be. In many families, problems in communication are among the main issues that need to be addressed in therapy.

D. Affective Involvement

This is the degree and quality of family members’ interest in and concern for one another. The following types of involvement have been distinguished:

• Lack of involvement. The family members occupy the same house but behave rather like strangers.
• Interest or involvement devoid of feelings.
• Narcissistic involvement. In this case, one family member is involved with another to bolster his or own feelings of self-worth, not because of any real concern for the other person.
• Empathic involvement. Here there is real caring and concern for the needs of the other person. This results in responses which meet the needs of that person.
• Overinvolvement, or enmeshment. This was described above.

E. Control

This is a measure of the influence the family members have on the behavior of other family members.

F. Values and Norms

This dimension appears only in the Process Model.

The above is but one of many schemata that are used by therapists of differing schools to understand the families that seek their help. It is quoted to give a flavor of the types of information that interest family therapists.

V. Helping Families Change

Promoting change is, of course, the essence of family therapy. To achieve this the therapist must have a coherent theory of change. This can be based on any of the theoretical schemes outlined above, or on others that exist. The therapist’s theory of change is then the basis for the interventions he or she employs. The actual techniques used vary widely, but certain stages are required:

a. The establishment of rapport. As rapport develops, the participants become intensively involved with each other; trust also develops. The process has been given other names; some therapists refer to it as ‘‘joining’’ the family or ‘‘building working alliances.’’ The process may occur quickly or it may take an entire session, even several. It involves both verbal and nonverbal techniques. Time spent establishing rapport is, however, seldom wasted. Lack of sufficient rapport is a major cause of failure in family therapy—and indeed in most endeavors that involve relationships with others.

b. Intervening in the family system. Having joined with the family, there are many ways the therapist may intervene in its transactional patterns. They may be divided into direct and indirect interventions.

A. Direct Interventions or Injunctions

Since family therapy aims to help families find new ways of functioning, a simple and straightforward approach is to offer the family suggestions, designed to help them make the changes that the assessment has shown to be needed in their way of functioning. The suggestions might be concerned with how family members could behave differently toward each other, or communicate more effectively, or alter their respective roles in the family—or whatever appears to be needed. They will also be related to the therapist’s theory of change.

Direct injunctions should be more than the giving of common-sense advice, because they must be based on a careful assessment of the changes the family needs to make. Families presenting for therapy, while aware that they have problems, or that family members have symptoms, often do not know what changes are needed to achieve the objectives they desire. Indeed, when asked what they are seeking from therapy, many family members reply by saying that they want answers to ‘‘why’’ questions such as: ‘‘Why is my child stealing?’’ ‘‘Why won’t my teenage daughter eat properly?’’ ‘‘Why have my husband and I drifted so far apart?’’

‘‘Why’’ questions are not unreasonable, but giving definitive answers to them is often difficult and frequently impossible. Who really knows the true motivation of anyone doing anything? It is generally better to focus on the changes that are desired by the participants, and how these may be achieved, than to spend time discussing the possible reasons why problems exist. The family members may be asked to describe, preferably in some detail, how things will be when treatment has come to a successful conclusion. (It is better to talk about when, not if, treatment has been successful; this is the process of ‘‘programming for success.’’) The desired state is sometimes referred to as the ‘‘outcome frame.’’

Once the outcome frame has been established the therapist, using the information that has been obtained during the assessment of the family, can then devise some interventions. Direct ones should probably be the first to be used, unless the history shows that they have been given a fair trial previously and have proved unsuccessful. Examples of direct interventions are:

• Rehearsing the family in communication techniques; these might aim to promote the direct, clear, and sufficient communication of information, opinions, and feelings between family members;
• Discussing the roles the various family members have been playing, and how these might be altered if it appears that alterations would be helpful;
• Proposing behavioral interventions to deal with undesired behaviors, or promote desired behaviors, on the part of the children;
• Suggesting, or modeling, more respectful ways for the family members to interact with each other;
• Helping family members to affirm and support each other, instead of the mutual criticism that is often encountered in families with problems.

Behavioral family therapy tends to use predominantly direct methods. The contingencies that appear to be controlling the behaviors that need to be changed are addressed directly.

Therapists of most schools are open to addressing dysfunctional patterns of interaction directly, and in some families this approach proves effective, especially when it is used in the context of a high degree of rapport. Unfortunately, especially in the more severely dysfunctional families, direct injunctions may be rejected or are not given an adequate trial even if lip service is paid to implementing them.

B. Indirect Interventions or Injunctions

The changes that may result from direct interventions, as outlined in the section above, tend to be what are often referred to as ‘‘first order change.’’ This implies that although the behaviors of one or more family members have changed, there have not been the more fundamental changes in the family that may be needed and are implied by the term ‘‘second order change.’’ Direct interventions may leave the functioning of the family system fundamentally unchanged, even though communication may be clearer, roles better defined, and so on.

The terms ‘‘strategic’’ and ‘‘systemic’’ are used for treatment approaches that aim to bring about more radical changes. These may involve alterations of perspective among the family members, so that some aspects of the way the family functions come to be viewed and understood in new ways. This is the process of ‘‘reframing’’—the giving of different meaning to behavior, feelings or relationships. In ‘‘developmental reframing,’’ for example, the antisocial behavior of an adolescent may be reframed as ‘‘immature,’’ rather than ‘‘bad.’’ ‘‘He’s not really a bad kid, he’s just having trouble growing up.’’ Getting a family, including the young person who is displaying the troublesome behavior, to see the problem behaviors in this light represents second order change. The very process of developmental reframing may affect the young person’s behavior. It may not be so acceptable to see oneself as immature, as opposed to being the strong, rebellious young person who does his or her own thing.

Many indirect interventions have been described. Here are brief descriptions of some of them:

• Reframing and positive connotation. Reframing— the giving of a different meaning to a behavior, or a pattern of behaviors—is the basic aim of most, if not all, indirect interventions. We have encountered one form—developmental reframing. Positive connotation is but a form of reframing, although it is an important one. For example, a parent’s abusive behavior toward a child may be reframed (positively connoted) as a laudable attempt to correct the child’s behavior. Therapy then can address the question of how the parent can develop better methods of achieving that goal. There are indeed few behaviors that cannot be positively connoted; what is required in doing so is the separation of the behavior from the motive behind it.
• Communication by metaphor. Metaphor is a long-established way of conveying messages indirectly and in a nonthreatening way. Situations may be reframed, new perspectives offered, and solutions to problems suggested without the issues being raised directly. Stories, anecdotes, other relationships, rituals, tasks, objects, and artistic productions may all carry meaning metaphorically.
• Paradoxical directives and related devices. When direct interventions have failed, it may be effective to suggest that, as ‘‘everything’’ has been tried, it may be better to leave things as they are. This effectively turns responsibility for change over to the family. Moreover, if they have, unconsciously, been trying to ‘‘defeat’’ the therapist, the only way they can now do so is by making the changes the therapist is advising against. Related to this are the declaring of therapeutic impotence and prescribing interminable therapy.
• Prescribing rituals and tasks. As we have seen, these may have metaphorical meaning, but they can also be used to interrupt repetitive, dysfunctional patterns of behavior. Examples are the ‘‘odd-days- even-days’’ routine, whereby parents take turns putting their children to bed; or the ‘‘same-sex parenting’’ plan, whereby the father is given responsibility for the boys in the family and the mother for the girls.
• Using humor. Helping family members to laugh at what they have been doing can, in the right situation, and in the context of profound rapport, be an effective change-promoting technique.
• Presenting alternative solutions or courses of action. This can be done by having the therapist admit to being uncertain about what is the best course of action and offering two or more; by having a ‘‘Greek chorus’’ observing though the oneway observation screen (a device widely used in family therapy) and sending in varying messages, or disagreeing with the therapist’s ideas; or by staging a debate in the therapy room, the observers coming in to discuss possible solutions. Such strategies have several potential advantages. They make the point that there are choices to be made and that there is not necessarily only one possible solution to a problem; they invite families to take some responsibility for making changes; and they operate from the ‘‘one-down’’ position, that is, the therapist( s) are not presented as all-knowing experts seeking to impose their solutions on the family.
• Externalizing the problem. This is a process whereby a symptom is labeled or personified. ‘‘ ‘Uncertainty’ has taken over your life.’’ ‘‘How can you win the battle with ‘Mr. Anger’?’’ The family, or an individual, is then invited to consider ways of defeating or otherwise dealing with the externalized object.

The above are but examples of what are often called strategic therapy techniques. Others have been described and only the creativity of the therapist limits the possibilities. Such techniques are not used only in family therapy; they have application in individual therapy as well as in other fields of endeavor such as teaching and selling.

Bibliography:

1. Barker, P. (1992). Basic family therapy (3rd ed.). Oxford: Blackwell.
2. Barker, P. (1996). Psychotherapeutic metaphors: A guide to theory and practice. New York: Brunner/Mazel.
3. Duvall, E. M., & Miller, B. C. (1984). Marriage and family development (6th. ed.). New York: Harper & Row.
4. Epstein, N. B., Bishop, D. S., & Levin, S. (1978). The McMaster model of family functioning. Journal of Marriage and Family Counselling, 4, 19–31.
5. Imber-Black, E. (Ed.). (1993). Secrets in families and family therapy. New York: Norton.
6. Madanes, C. (1981). Strategic family therapy. San Francisco: Jossey-Bass.
7. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
8. Nichols, W. C. (1996). Treating people in families: An integrative framework. New York: Guilford.
9. Palazzoli, M. S., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox. New York: Jason Aronson.
10. Steinhauer, P. D., Santa-Barbara, J., & Skinner, H. (1984). The process model of family functioning. Canadian Journal of Psychiatry, 29, 77–88.
11. Whitaker, C. A. (1976). The hindrance of theory in clinical work. In P. Guerin, (Ed.), Family therapy: Theory and practice. New York: Gardner.

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