Family Therapy and Theory
The Structural Model
"Family structure is the invisible set of functional demands that organize the ways in which family members interact" (Minuchin, 1974, p. 51). An individual's symptoms are best understood as rooted in the context of family transaction patterns. Change in family organization or structure must take place before the symptoms are relieved. The therapist must provide a directive leadership role in changing the structure or context in which the symptom is embedded
Experiential Models Symbolic- Experiential Family Therapy
(S-EFT) includes several generations of family in efforts to change the often rigid & repetitive ways of interacting to those that are more flexible & spontaneous. Therapist may draw on personal experiences, images & fantasies. Replacement of preplanned therapeutic technique with therapist's own spontaneous creativity. Use of co-therapy teams. Pioneered by Carl Whitaker; treated patients in Oak Ridge in 1941.
Detouring Coalition
2 united family members hold a 3rd member responsible for their difficulties with another.
Stable Condition
A fixed & inflexible union that becomes the dominant part of the family's everyday functioning.
Social Construction Models I: Solution- Focused Therapy and Collaborative Therapy
A move away from hierarchy: Flattening of the therapeutic relationship Reduction of therapist's "expert" status Reality Invented not Discovered: An epistemological shift Basic Characteristics of Social Constructionist Theories: Egalitarianism in therapeutic relationship Client as expert Assumptions about the problem are explored Goal of helping clients explore new meaning
Experiential Models Symbolic- Experiential Family Therapy Cont'd
Aim to normalize human behavior by largely removing psychopathogy; idea that psychopathology arises from the same mechanisms that produce "normal" behavior. Encourage "craziness" believing that this will spark new outlooks and creative solutions. Growth as a goal takes precedence over achieving stability or specific planned solutions. (Results in long term solutions.) The family unit is the patient.
Strategic Models MRI Interactional Family Therapy: Axioms of Interpersonal Communication
All behavior is communication at some level. Communication may occur simultaneously at many levels. Every communication has a content & a relationship aspect. Relationships are defined by command messages. Relationships may be described a symmetrical or complementary. Symmetrical relationships risk becoming competitive. Complementary communication inevitable involved one person who assumes a superior position and another an inferior one. Each person punctuates a sequence of events in which they are engaged in different ways. Problems develop and are maintained within the context of redundant interactive patterns & recursive feedback loops.
The Structural Model Underlying Assumptions Cont'd
All family systems desire homeostasis: each individual member desires to stabilize the system and contributes their part to balance the system so that they can continue to be satisfied by the system (Minuchin, 1974) Therapists work collaboratively with families, not as experts who can solve problems, but as consultants and coaches who work to bring the family's dormant capacities to the surface. Therapists respect the family's unique culture. The question should be, not "What's ideal?" but "Does it work for them?"
Coalition
Alliances between specific family members against a 3rd family member. (Siblings may do this- the two oldest vs the youngest.)
Structure
An organized pattern in which families interact, not deterministic or prescriptive, only descriptive. Can only be seen when a family is in action, because verbal descriptions rarely convey the true structure.
Nuclear Family Emotional System
An unstable, fused family's way of coping with stress, typically resulting in marital conflict, dysfunction in a spouse, or psychological impairment of a child; their pattern is likely to mimic the patterns of past generations and to be repeated in future generations. Describes for basic relationship patterns that govern where problems develop in a family.
Experiential Models
Based in phenomenological, humanistic, and emotionally focused therapy. Interventions are individualized to the patient and/or family by a personally involved therapist. All models emphasize choice, free will, and the human capacity for self-determination & self-fulfillment. Disorders & dysfunction are often viewed as failure in the growth process- a deficiency in actualizing one's capabilities & possibilities. Free Choice, Free Will, etc. Existentialism
Psychodynamic Models Classic Psychoanalytic Theory (Father- Freud)
Biologically determined forces (drives) within a person as a basis for understanding motivation, conflicts & symptomatology. Each drive with 4 components (aim, source, impetus, & object). Ideas of transference, countertransference, resistance & interpretations. Challenging Interventions Examples: Sex or Food (There is a source for this drive, and there is an end game for this drive.)
Societal Regression
Bowen's notion that society responds emotionally in periods of stress and anxiety, offering short-term "Band-Aid" solutions, rather than seeking more rational solutions that lead to greater individuation.
Emotional Cutoff
Bowen's term for flight from an unresolved emotional attachment. Describes people managing their unresolved emotional issues with parents , siblings, and other family members by cutting off emotional contact with them.
The Therapeutic Process in Narrative Therapy
Collaborate with the client in identifying (naming) the problem Separate the person from his or her problem Investigate how the problem has been disrupting or dominating the person Search for exceptions to the problem Ask clients to speculate about what kind of future they could expect from the competent person that is emerging Be an audience to support the new story
Alignment
Defined by the way family members unite or oppose each other in carrying out a family activity.
Psychodynamic Models Intersubjective Psychoanalysis
Developed in 1990's & is similar to self-psychology Every interaction (parent-child or patient -therapist) takes place within an "intersubjective field"; a dynamic psychological system made of up reciprocally interacting & differently organized subjective worlds. These recurrent patterns of intersubjective transactions between 2 people result in the establishment of "organizing principles"; these unconsciously pattern subsequent experiences.
Strategic Models MRI Interactional Family Therapy: Paradoxical Injunction
Double-blind message occurring when one person (esp a person in a powerful positions) issues an injunction to another that simultaneously contains 2 levels of messages or demands that are logically inconsistent & contradictory. The recipient is unable to avoid the incongruity or to comment on the impossibility of meeting it's requirements, resulting in confusion. *must be obeyed but must be disobeyed in order to be obeyed* Ex: Do not follow these instructions.
Experiential Models Human Validation Process (8)
Eight Aspects of the Self (Exactly what you thing these would stand for. Little box in book that describes.) 1.Physical 2.Intellectual 3.Emotional 4.Sensual 5.Interactional 6.Contextual 7.Nutritional 8.Spiritual
Transgenerational Models Bowen's Family Systems: 8 Interlocking Concepts
Eight Interlocking Concepts; none are fully understandable apart from the others. All are tied together by the premise that chronic anxiety is omnipresent in life. 1.Differentiation of self (FIND DEFINITIONS IN BOOK) 2.Triangles 3.Nuclear family emotional system 4.Family projection process 5.Emotional cutoff 6.Multigenerational transmission process 7.Sibling position 8.Societal regression
Social Construction Models: Narrative Therapy
Emphasize the quality of therapeutic relationship, in particular therapists' attitudes Client-as-expert, clients are the primary interpreters of their own experiences Therapists seek to understand client's lived experience and avoid effort to predict, interpret, and pathologies.
Experiential Models Human Validation Process
Emphasizes the collaborative efforts of therapist & family members to achieve family wellness. Open communication is key; members learn to express feelings openly, congruently, and without defensiveness. Symptomatic behavior was "adaptive attempts gone awry"- Satir Emphasized triads: Primary Survival (father, mother, child) & Mind, Body, Feeling of individual growth.
Psychodynamic Model Self- Psychotherapy
Emphasizes the relationship between the self & outside objects; based on work with narcissistic personality disorders. Infant experiences a parent narcissistically as "self objects": a sense of oneself in relation to an other that is needed for sustenance or enhancement of the self. Analyzed by exploring the self object transference. Qualities needed from parents: empathy & idealization. Mirroring: acceptance of (parent or therapist) of another person's narcissistic self such that the person being mirrored may experience self-acceptance.
Social Construction Models: Narrative Therapy Therapeutic Techniques
Externalization & Deconstruction Externalization is a process of separating the person from identifying with the problem Externalizing conversations can lead clients in recognizing times when they have dealt successfully with the problem Problem-saturated stories are deconstructed (taken apart) before new stories are co-created
The Structural Model Underlying Assumptions
Families (people) are competent and capable of solving their own problems -- an attitude derived from the existential-humanistic tradition Rigidity of transactional patterns and boundaries prevents the exploration of alternatives. Symptoms are a by-product of a structural system that is failing The system fails to nurture growth or deal with crisis of its members. A family system is therefore stabilized by each member's contribution. Subsystems are organized hierarchically : power is distributed appropriately within individuals and between subsystems, making reliance on some members more expected than on others.
Differentiation of Self
Families and other system effect how people think and feel how and act. Groups vary in the amount of pressure they exert for conformity.
Transgenerational Models Bowen's Family Systems
Family as an emotional unit that is best understood through multigenerational/ historical framework. Family members seek balance in both togetherness & individual autonomy. Based in Bowen's interest in the possible transgenerational, symbiotic (enmeshment) in the development of schizophrenia. (The long range of generational family and how different generations impact one another.)
Experiential Models Gestalt Family Therapy
Focus is on how patients perceive their immediate existence. Change occurs with the individuals thoughts and feelings become congruent "lose your mind and come to your senses"- Perls Attention is focused on the immediate "What people say, how they say it, what happens when it is said, how it corresponds with what they are doing, and what they are attempting to achieve" (Kempler). Forces participants to talk to each other, not the therapist to disclose openly & honestly how they feel.
Strategic Models
Focus is on how verbal and nonverbal messages are exchanged within a family. What is occurring rather than why and the ways in which it they interact, define & redefine their relationships. 4 perspectives: Mental Research Institute (MRI) Interactional View, Brief Therapy, Strategic therapy refinements & Strategic-related efforts developed in Milan. Efficiency & technical parsimony are the hallmarks of all these models; change oriented and brief in duration. All four perspectives view families in nonpathological terms.
Experiential Models Emotionally Focused Therapy
Focus is on the process between people, not what is inherent in each person Attempts to explore the patterns that block emotional engagement Short-term (8-10 sessions) 3 stages: De-escalation of negative cycles & stabilization Creation of new stance & patterns of interaction that foster open responsiveness & more secure bonding allowing for attachment needs to surface & be met in a "transforming emotional connection" Consolidation/ Integration
Strategic ModelsMRI Interactional Family Therapy: The Therapeutic Double- Blind
Forces families to examine patterns of communication Used to change entrenched family patterns Intended to force a person, couple or family into a "no-lose" situation *ex advising a depressed patient to not be in such a hurry to give up the depression.
Strategic Models MRI Interactional Family Therapy
Founded by Don Jackson, Virginia Satir & Jules Riskin in 1959- Mental Research Institute in Palo Alto Largely based on general systems theory, cybernetics & informational theory in efforts to identify how faulty communication patterns could lead to family dysfunction Semantics, syntax & pragmatics
Strategic Models Post- Milan: Reflexive Questioning (Pg 309)
Future oriented Observer-perspective Unexpected counterchange Embedded suggestion Normative-comparison Distinctive-clarifying Questions introducing hypothesis Process-interrupting
Transgenerational Models Contextual Therapy
Heavily influenced by Object Relations Theory, Existential philosophy and interpersonal psychiatry Adds "ethical perspective"; trust, loyalty, transgenerational indebtedness, entitlements, & fairness in relationships between family members Core concept of Relational Ethics: long-term, oscillating balance of fairness among family members Use of metaphorical "family ledger" who owes who; or when someone has done something to somebody. "Remember that time you did me wrong and now you owe me." Holding it over their head. A book that rarely gets balanced. Introduced concept of "family legacy" may be the way a child when older perceives a how a relationship should be, how a significant other should be, how religion should play in a relationship or family. A family dynamic that has been going on for a long time. BOTH positive and negative.
Psychodynamic Model Object Relations Cont'd...
Holding Environment: the safe & nurturing environment created by the "mother" that allows for psychological development. Shared- Holding: the environment a therapist attempts to create for the sake of psychological healing/ growth. Family-of-Origin within marital relationships.
Experiential Models Human Validation Process: Four Dysfunctional Communication Stances
If in conflict- may not be the best way to communicate. Otherwise, ok.
Transgenerational Models Bowen's Family Systems Cont'd
In therapy, it is important for the therapist to maintain objectivity rather than emotional reactivity. Do not take sides or be emotionally involved. Likely to be unwittingly triangulated; it is beneficial to remain in this triangle as long as the therapist is not caught in the emotional process; the nonanxious presence in this triangle can induce change that would otherwise not take place in the absence of the therapist Use of I-statements.
Sibiling Position
Incorporates the research of psychologist Walter Toman as a foundation concept of sibling position.
Psychodynamic Model Object Relations Cont'd
Individuals interact within current relationships based on an internalized representation of another person from the past. Fairbairn's contributions: "Splitting"; child creates a fantasy world to make sense of the conflicting developing views of the "mother"- nurturing & frustrating/ harmful. Most children can integrate these views into a "whole person" but those that can't may develop tendency to view others as "all good" or "all bad".(BPD)
Psychodynamic Model Object Relations
Infant's relational experiences with the primary care-giver as the main determinant factor of adult personality. Combines attention to individual drives, development of self & unconscious relationship-seeking. Infant's need for attachment to a "mother" is there foundation for development of the self. "Object" refers to instinctual drives or internal (typically unconscious) views a person holds of an individual from past childhood experiences.
Boundaries
Invisible barriers that regulate contact between members. Diffuse, too weak, or "enmeshed". Rigid, too fortified, or "disengaged". Are reciprocal; enmeshment in one demands disengagement from another. Enmeshed: (Mother comes to appointment and makes decisions for 30 years old son. Teenager acts younger and is very dependent upon parent maybe still sleeping in bed with parent.) Disengaged: (Authoritarian household- carries over past expiration date. Father who comes home and kids should be seen and not heard.)
Triangles
Is a three person relationship system. Is a building block or molecule of larger emotional systems because triangle is the smallest system.
Social Construction Models II: Narrative Therapy
Leading Figures- White & Epston Self and cultural narratives Oppression and its role in problem development and maintenance Therapeutic Conversations: Externalizing the problem Therapeutic questions Unique outcomes Co-constructing alternative stories Therapeutic ceremonies and letters Forming supportive leagues
Behavioral and Cognitive- Behavioral Models
May include use of therapeutic contracts More often including aspects of social-learning theory Integrative couples therapy; goal to assist couple to build tolerance of the inevitable differences between them
The Structural Model
Monitoring Family Dysfunctional Sets Family Mapping Boundary Making Unbalancing Tracking Enactments Restructuring Transactional Patterns Reframing Increasing family stress (Paper is with relationships. Leader, rigid boundary, etc. for example.)
Social Construction Models: Narrative Therapy Therapeutic Techniques
No recipe, no set agenda, and no formula This approach is grounded in a philosophical framework Questions—and more questions: Questions are used as a way to generate experience rather than to gather information Asking questions can lead to separating "person" from "problem", identifying preferred directions, and creating alternative stories to support these directions.
Strategic Models MRI Interactional Family Therapy: Paradoxical Communication
No such thing as a simple message: people communicate constantly in verbal & nonverbal ways.
Psychoeduational Models: Teaching Skills to Specific Populations
Not necessarily theory-driven Aimed at how to help families maximize their effectiveness with a specific concern, often severe mental illness Schizophrenia as an example: Role of expressed emotion (EE) in family functioning Works with Single Families or Multiple Family Groups Medical Family Therapy: Biopsychosocial model Family therapist-physician partnerships Family therapist-family partnerships
Strategic Models Milan Systemic Model
Now known as Systemic Family Therapy Shifted focus of treatment away from the observation of interactive sequences and patterns toward questioning family belief systems. Key therapeutic concepts: counterparadoxes (double-blinds), positive connotation and rituals.
Triangulation
Occurs when 2 family members who are at odds, involved a 3rd member with efforts to manipulate in order for the 3rd to take their side. Often results in a "no win" situation with negative outcomes.
Strategic Models (STFT)
Offer active & straightforward therapeutic interventions aimed at reducing or eliminating presenting problems/ symptoms. Stem from family communication theories. Other influences: feedback loops (most central), redundancy principle, double blinds, family rules, marital quid pro quo, and family homeostasis. Most characteristic of family therapy today.
The Structural Model Cont'd
Parents must form healthy Spousal Subsystem. Must develop complementary patterns of mutual support, or accommodation (compromise). Must develop a boundary that separates couple from children, parents and outsiders. Must claim authority in a hierarchical structure.
The Structural Model
Power & Heirarchy Person with the most power makes the final decisions and takes responsibility for the outcome of the family dynamics. Appropriate persons to have power in families are the parents. Ex: parent tells a child not to play video games, the child obeys because the parent has consistently shown the child that they expects compliance in the child. In dysfunctional families children may be given more attention than the couple gives each other, and the child is therefore given control. This leaves the child insecure as they are not mature enough to have such power and cause parents to continue their conflict over the child rather than deal with their own issues. The child acts out as a result.
Social Construction Models I: Solution- Focused Therapy and Collaborative Therapy: Techniques
Pre-therapy- simply scheduling an appointment often sets positive change in motion, and often you will ask during the initial therapy session, " What have you done since you called for the appointment that has made a difference in your problem?". Exception Questions- to direct clients to times when the problem did not exist, or when it would be reasonable to have expected the problem to occur, but somehow it did not (de Shazer, 1985; Murphy, 2008). The miracle question- asking clients "If a miracle happened and the problem you have was solved over-night, how would you know it was solved, and what would be different?". With the main theme being "What would be different?"
Strategic Models Strategic Family Therapy
Problems-solving & specific goal oriented Problems defined as involving 2-3 people Change occurs as the family carries out directives issued by the therapist Very similar to Structural Therapy; triangles, sequences & hierarchies. Focus is on "artfully alleviating" the presenting problem rather than exploring it's roots. Use of advice, direct suggestions, coaching, homework, even assignments
Models of Family Therapy
Psychodynamic Transgenerational Experiential Structural Strategic Behavioral & Cognitive- Behavioral Social Construction (For the test have a general idea of the 5/6 models.)
Psychoeduational Models: Teaching Skills to Specific Populations
Relationship Enhancement Programs Premarital Education Programs Marital Enrichment Programs (Marriage Encounter): Research-based Stepfamily Preparation Programs
Techniques
Scaling questions- change in humans is not easily observed such as, feelings, moods, or communication so scaling on say a 1-10 scale to assist clients in noticing they are not completely defeated by their problem. Formula first session task- is a form of homework a therapist might give clients to complete between their first and second sessions. Therapist feedback to clients- generally SFBT practitioners take a 5 to 10 minute break toward the end of the session to compose a summary message for the client.
Social Construction Models: Narrative Therapy Therapeutic Techniques
Search for unique outcomes Successful stories regarding the problem Creating Alternative Stories The assumption is that people can continually and actively re-author their lives Invite clients to author alternative stories through "unique outcomes" An appreciative audience helps new stories to take root
Behavioral and Cognitive- Behavioral Models: Conjoint Sex Therapy
Sex as a metaphor for couple dynamics Need for sexual education Skills building Masters and Johnson Sensate focus, systemic desensitization, communications training David Schnarch Donald Meichenbaum
Strategic ModelsMRI Interactional Family Therapy: Relabeling
Simply changing the label from negative to positive in attempts to alter the meaning of the situation. *overprotective vs helpful
Social Construction Models I: Solution- Focused Therapy and Collaborative Therapy
Solution- Focused Brief Therapy (SFBT) Steve de Shazer & Insoo Berg Solution Talk Therapeutic conversations Miracle questions Exception-finding questions Scaling questions
Social Construction Models I: Solution- Focused Therapy and Collaborative Therapy
Solution- Oriented Brief Family Therapy Leading Figures - O'Hanlon & Weiner-Davis Goal-Oriented (as defined by the client) Resistance not a useful concept Change is inevitable Only a small change is necessary Clients have the strengths and resources necessary to change. Problems are unsuccessful attempts to resolve difficulties In-depth problem knowledge is not required Multiple perspectives
The Structural Model Therapeutic Goals
Structural changes must first occur within the family, therefore, the therapist focuses on changing the experience of family members: Not a matter of creating new structures, but reforming existing ones Therapy is directed at altering the family structure and creation of an effective hierarchy Boundaries must be strengthened in enmeshed relationships, and weakened (or opened up) in disengaged ones. What distinguishes SFT from other forms of family therapy is the emphasis on modifying family structure in the immediate context of the therapy setting. When new patterns are repeated and result in improvement of family relationships, they will stabilize and replace old patterns and symptoms of dysfunction will be reduced or disappear.
Subsystems
Sub-groupings within the family based on age (or generation), gender and interest (or function). Parenting, spousal and sibling.
Social Construction Models: Narrative Therapy Therapist Role
Suggest alternative viewpoints and elicit stories Mirroring- reflect themselves as well as the client Emphasis on being respective & encouraging of client's strengths and resources Participatory witness and interpersonal relationship based on collaboration not just reflection (person-centered) but interactive Careful listening, empathetic, summarization and paraphrasing to give people ownership To demonstrate care, interest, respectful curiosity, openness, empathy, contact, and fascination To adopt a not-knowing position that allows being guided by the client's story To help clients construct a preferred alternative story To separate the problem from the people (instead of person own the problem) To create a collaborative relationship --- with the client being the senior partner
Techniques Cont'd
Terminating- this is what the therapist and client are going for, first by setting goals to overcome said problem and then getting to the point where therapy is no longer necessary. Group counseling- believing people are competent, and that given a climate where they can experience their competency, they are able to solve their own problem, enabling them to live a richer life. Reflecting Team Approach Listening-to-Each Other Process The Democratization of Therapy
Social Construction Models II: Narrative Therapy
The Narrative Metaphor We live our lives through the stories we construct. Our lives as multi-storied. The dominant discourse or story. Poststructuralism and deconstructionism. Thick and thin descriptions. Self narratives and cultural narratives.
Family Projection Process
The primary way parents transmits their emotional problems to a child.
Multigenerational Transmission Process
The way in which dysfunctional patterns are passed from one generation to the next. Describes how small differences in the levels of differentiation between parents and their offspring lead over many generations to marked differences in differentiation among the members of a multigenerational family.
Psychodynamic Models Relational Psychoanalysis
Theory assessed the impact of the outside events, personal relationships & patient's inner world on the developing psyche: interpersonalists. Two- Person Therapy; current term used by theorists to describe the mutual relationship of therapist & patient in the therapeutic encounter. Occurs within an intersubjective field. Concept that both therapist & patient are equals who participate equally; this "meeting of the minds" results in a "co-constructed" psychic experience that can lead to healing for both. Selective self-disclosure; goes against commonly held opinion of inappropriate countertransference. Rejection of "blank screen" approach. (You as the therapist do not give anything of yourself to the pt.)
Social Construction Models: Narrative Therapy
Therapeutic Goals Therapists invite clients to describe their experience in new language and facilitate the discovery or creation of new options that are unique to them
The Structural Model Therapist's Role
Therapist doesn't solve problems, that's the family's job; therapist's task is to break the certainty of the family of what the problem is or who the "problem" is. This confusion helps family members to rethink their roles and try out new ones. The therapist tries to help the family create permeable boundaries and subsystems. The therapist intervenes with the family actively during sessions by assuming a leadership position. Maps the family's underlying structure (boundaries, hierarchy, subsystems). Intervenes to transform the structure with direct requests to the family to change how the members interact with each other.
Strategic ModelsMRI Interactional Family Therapy: Prescribing the Symptom
Therapist try to produce a runaway system by urging or coaching the client to engaged in or practice his or her symptoms, at least for the present time. *ex- family is instructed to continue or exaggerate what is already going on, such as arguing daily or for 15 mins every day after dinner.
Strategic Models MRI Brief Family Therapy
Time limited- no more that 10 session The client's complaint is the problems, not a symptom of an underlying disorder "think small & go slow" Treatment team approach but may be "behind the scenes" Telephone follow-up at 3 and 12 months after termination
Experiential Models Human Validation Process
Use of Family Life Fact Chronology Family Reconstruction; guides families to unlock dysfunctional patterns stemming from family of origin. Blends elements of Gestalt, guided fantasy, hypnosis, psychodrama, role play & family sculpting.
Behavioral and Cognitive- Behavioral Models
Use of Reinforcements & application of behavioral parent training Used for specific behavioral problems: poor communication between spouses or acting out behavior in children. Behavioral couples therapy- based in operant conditioning Keys of assessment: behavioral analysis, problem analysis, functional analysis
The Structural Model Concepts
Wholeness, Hierarchy, & Subsystems Family Structure: Operational rules Interactive routines Transactional patterns Complementary patterns Instrumental/expressive roles
Hypothesizing
continual interactive process of speculating and making assumptions about at family situation, guides the systemic interview; the goal is change, not truth
Circular Questioning
involved asking each family member questions that address a difference or define a relationship between two other members of the family.
Strategic Models MRI Interactional Family Therapy: Second Order Changes
require fundamental revision of the system's structure & function. Therapist aids family to alter its systemic interaction pattern and reorganize the system so as to reach a different level of functioning.
Strategic Models MRI Interactional Family Therapy: First Order Changes
superficial behavioral changes within a system that do not change the structure of the system itself. Linear, cosmetic or simply a reflection of a family's good intentions Likely to be short lived
Neutrality
therapist is interested in and accepts without challenge each member's unique perception of the problem
