Michael Cornwall, PhD, PsyD
Lindsey Wilson College
School of Professional Counseling
Introduction
On Being A Family
Therapist
•Family therapy is a branch of
psychotherapy that works with
families and couples in intimate
relationships to nurture change
and development.
• It tends to view change in terms
of the systems of interaction
between family members.
• It emphasizes family
relationships as an important
factor in psychological health.
• What the different schools of
family therapy have in common is
a belief that, regardless of the
origin of the problem, and
regardless of whether the clients
consider it an "individual" or
"family" issue, involving families
in solutions is often beneficial.
Dysfunctional Family
• This class is NOT about
dysfunctional families
• Dysfunction is defined as
functioning incorrectly or
abnormally
• Abnormality, in this sense, is
something deviating from the
normal or differing from the
typical
• It is a subjective definition based
on culturally accepted behavioral
rules and expectations
Dysfunctional Family
• All families have their ups and
downs, unusual characters, good
and poor choices, rituals and
beliefs
• No one and no family is in perfect
homeostasis at all times
• Therefore, there are NO
dysfunctional families
– All families function
• There are families that function
more optimally, more or less
often, than others
Focus on Human Developmental and
Personality Theory
• Erik Erikson (15 June 1902
– 12 May 1994) was a
developmental psychologist
and psychoanalyst known
for his theory on social
development of human
beings.
• Abraham Maslow
(April 1, 1908 – June 8,
1970) was an American
psychologist. He is
noted for his
conceptualization of a
"hierarchy of human
needs,” and is
considered the founder
of humanistic
psychology.
CHAPTER 1
The Evolution of Family Therapy
The Early Years
Shift in Perspective
• The evolution of family therapy is really about
– Personalities
– Ideas
• Treating patients with schizophrenia in hospitals
• Noticed that when one family member got better,
someone else would get worse
• Hypothesized that the family needed a symptomatic
family member
– Case study of the depressed woman and her husband
– His stability was predicated on having a sick wife
Influence of Group Therapy
• Group Therapy: A complex blend of individual
personalities
• Group concepts borrowed for family therapy:
– Kurt Lewin theorized that groups are psychologically
coherent wholes, not collections of individuals
– Lewin’s ideas about “unfreezing” (shaking up a group’s
beliefs) foreshadowed family therapists’ concerns with
disrupting family homeostasis
– Focus on “process” (how people talk), rather than “content”
(what they talk about)
– Role theory (too few – limiting, too many – overload,
rigidity vs. flexibility, role conflict, learned family roles)
Child Guidance Movement
• Real source of children’s problems were not from themselves,
but from tensions in the family that created symptoms
• Frieda Fromm-Reichmann (1948) – The schizophrenogenic
mother
– Domineering, aggressive, insecure woman; married to a passive,
inadequate, and indifferent man
– Provided pathological parenting that produced schizophrenia
• Eventually emphasis in child guidance shifted to viewing
parents solely as the problem, to viewing the interaction that
was the problem – Bowlby, Ackerman
Influence of Social Work
• Social workers among the leaders of family
therapy
• Social workers considered families as whole
units and viewed the family as a system
functioning within larger systems
• Social work students were taught to interview
both parents at the same time to get a complete
picture of family’s problems
Etiology of Schizophrenia
• Gregory Bateson
– One of the first family researchers
• Developed communications theory
– Homeostasis – Feedback which regulates the behavior of
the family and preserves the family equilibrium
– Double-bind
• Craziness stemmed from an extension of the family environment –
receiving two related but contradictory messages
• Difficult to detect and comment on the inconsistency
• Lidz, Wynne and role theorists
Marriage Counseling
• Began as informal procedure
• Currently practiced outside of traditional
mental health settings
– Ministers, family doctors, lawyers
• Couples therapy was absorbed into the theory
and practice of family therapy
• Empirically supported and expanding field
Pioneers of Family Therapy
• John Bell
– Family group therapy
• Palo Alto group
– Communications Theory
• Gregory Bateson – cybernetics
• Don Jackson – family homeostasis
• Jay Haley – strategic family therapy
Pioneers of Family Therapy
• Murray Bowen
– Believed people who are helped resolve emotional
problems by working with family-of-origin
– Argued that pathological mechanisms found in
schizophrenic families were present to a lesser
degree in all families
– Goal is to help partners achieve a reasonable level
of differentiation of self within the context of their
family relationships
Pioneers of Family Therapy
• Nathan Ackerman
– Moved away from psychoanalysis
– Wanted to see everyone together
– Interested in family secrets, conflicts
– Agent Provocateur
Pioneers of Family Therapy
• Carl Whitaker & Virginia Satir
– Experiential Family Therapy
• Believed people were alienated from their emotions
• Favored spontaneity vs. theory
• Used co-therapy
• Ivan Boszormenyi-Nagy
– Ethical accountability
– Relationships based on trust and loyalty
Pioneers of Family Therapy
• Salvador Minuchin
– Structural Family Therapy
• Begins with observation that family transactions, when
they are repeated, develop a pattern of regularity or
structure
• Family structure is determined by emotional boundaries
– Enmeshed
– Disengaged
CHAPTER 2
Lessons from Early Models
Background and Leading Figures
• Influence of schizophrenia project led to a
combination of group therapy and communications
theory
• John Elderkin Bell
– One of the most influential pioneers of family therapy
• Communications therapy
– One of the earliest and most influential approaches to
family therapy
• Developed by Don Jackson and Jay Haley
Theoretical Formulations
• Freud authored the first major text on treating the group
• Identification
– Members identify with the leader as a parent surrogate and the
others as siblings
• Transference
– Occurs in groups when members repeat unconscious attitudes
formed in the process of growing up
• Resistance
– Avoid process of treatment through silence, hostility, missing
sessions, etc.
Theoretical Formulations
• Wilfred Bion
– Group psychology of the unconscious
• Manifest level: group’s official task
• Latent: dependence, pairing, fight-flight
• Kurt Lewin
– Field theory: conflict is an inevitable feature of group life
– Level of conflict determined by amount of restriction compared
with support
– Different in that it was historical and focused on here and now
• Black box concept
– Disregards the individual and focuses on communication within
the group
Communication Relationships
• Complementary or Symmetrical
– Complementary: based on differences that fit together
(e.g., assertive vs. permissive)
– Symmetrical: based on equality; behavior of one mirrors
the other
• Assumption of circular causality and interactions
– Feedback loops: behavioral change
• Positive feedback loop – when the responses to one family
member’s problematic behavior exacerbates the problem
Normal Family Development
• Described as functional systems, which depend on two
processes:
– Negative feedback
– Positive feedback
• Normal families may become unbalanced, experience stress
– Normal/healthy families avoid destructive patterns through
positive feedback
– Symptomatic families remain stuck in negative feedback
– The channel for positive feedback is communication –
healthy families communicate clearly and are flexible
Development of Behavior Disorders
• Group Theory • Communications Theory
– Group Dynamics – Maintain the equilibrium
(Circular Causality) of family system
– Conditions perpetuate – The identified patient
psychopathology was considered a role
– Rigidity of roles forces with complementary
group interactions to counter-roles, all of
occur in a narrow range which contribute to the
causing malfunction maintenance of the
system
Goals of Therapy
• Group Family Therapy • Communications Family
– Promoting individualization Therapy
of family members – Deliberate action to alter
– Improving relationships poorly functioning patterns of
– Verbalizing unmet needs and interaction
understanding them – Patterns of interaction are
– Expanding rigid roles synonymous with
communication
• Communicate about the
family, communicate
about the problem, change
the symptom
Conditions for Behavior Change
• Group Family Therapy • Communications Family
– Sit down and talk to one Therapy
another openly; therapist is – Symptoms considered as
supportive and critiques the covert messages commenting
process on relationships (e.g.,
– Promotes communication by headache is a report of how
focus on process over content someone feels from family
tension)
– One of the most important
ways to change behavior is to
bring hidden messages into
the open
Group Techniques
• Group Techniques • Communications
– Multiple Family Group Techniques
Therapy: treat 4-6 families – Teaching rules of clear
together weekly communication, analyzing
– Multiple Impact Therapy: and interpreting
meet with various communication patterns, and
combinations of family manipulating interactions
members and then assemble a through a variety of strategic
large group maneuvers
– Network Therapy: assist – Emphasis on the need for
families in crisis by structure and control in family
assembling their entire social meetings
network in gatherings of as
many as 50 people
CHAPTER 3
Basic Techniques of Family Therapy
The Stages of Family Therapy
• Goals for initial phone call
– Overview of problem
– Arrange for family to come in for consultation
• Primary objectives for first interview
– Build alliance with the family
– Gather necessary information
– Formulate hypothesis about what is maintaining
problem
The Stages of Family Therapy
• Early phase of treatment
– Refine therapist’s hypothesis
– Begin work with family to resolve
• Middle phase of treatment
– Take less directive role
– Encourage family to rely on their own resources
– Encourage family members to talk amongst
themselves
The Stages of Family Therapy
• Termination
– When family has resolved presenting problems
– When family feels they can manage their lives
without professional help
It’s useful to review what was learned with the
family at this stage
Family Assessment
• When hearing presenting problem, remember that
every case is unique
• Listen carefully to the family’s account of the
problem and ask detailed questions
• Consider the systemic context, stage of family life
cycle, family structure, and communication problems
• Be sensitive to gender inequalities, cultural issues,
and ethical issues
The Ethical Dimension
• Be aware of the ethical responsibilities of the
counseling profession:
– Refer to the American Counseling Association (ACA)
Code of Ethics
• Be aware of “red flags” signaling unethical practices:
– (e.g., specialness, attraction, alterations in the therapeutic
frame, violation of clinical norms, professional isolation)
CHAPTER 4
The Fundamental Concepts
of Family Therapy
Foundation
• Concepts: • Before, looked at
– Anthropology individual through their
– Biology family
– Philosophy • Now look at:
– Linguistics – Family structure
– Computer Science – Long-term
– Engineering multigenerational
processes
– Cultural influences
Cybernetics
• “Study of machines that regulate themselves”
– Behavior in families is consistent
– Change in families is very difficult
• Feedback loops – how a system gets
information necessary to maintain a steady
state
– Introduced by Gregory Bateson
Cybernetics
• Cybernetics focuses attention on:
– Family rules that govern the family’s homeostatic
range
– Negative feedback/mechanisms that families use to
enforce those rules
– Sequences of family interaction around a problem
that characterize the system’s reaction to it
– What happens when the system’s negative
feedback is ineffective, triggering positive
feedback loops
Cybernetics
• Examined negative feedback (mechanisms used to
enforce family rules) and positive feedback loops
(when negative feedback is ineffective). Positive
feedback loops either destroy a system or can help it
adjust to changed circumstances.
• Cybernetically oriented therapists strived for second-
order change, distinguishing it from first-order
change
– Second-order change – change in the family rules
– First-order change – family changes behavior, but
is still governed by the same rules
Systems Theory
• System
– “An organized group of elements that function as a single
entity”
• Family is more than a collection of individuals; it is
an organized network of relationships
• Systems can be understood by looking at process and
structure
– Process: patterns of interaction
– Structure: the arrangement of the interacting components
• Linear vs. circular causality
General Systems Theory
• Developed by Ludwig von Bertalanffy (Austrian
biologist)
– Critical of cybernetics
• Believed science had become reductionistic
– i.e., looking at a machine’s parts without examining its
relationship to other parts
• Many of his ideas include:
– Concept of a system as more than the sum of its parts
– Emphasis on systems as subsystems of larger systems
– Thinking interaction and studying whole systems
– Open systems: those which continually interact with the
outside environment
Constructivism
• Epistemological paradigm according to which
knowledge is actively construed by the observer
• Implications for family therapy are:
– Greater emphasis on cognition
– Greater emphasis on the subjective experience of
individual family members
• Moved family therapy in direction of individuals’
cognitive experience and away from traditional
emphases of family therapy
• Emphasis on reframing: relabeling behavior to shift
how family members respond to it
Social Constructivism
• Expands constructivism; takes into account
that the way we perceive and relate to the
world is shaped by our social context
• Therapy is a process of deconstructing
unhelpful narrative accounts of experience and
then helping people reconstruct more
promising ways of looking at things
• Most direct application is found in narrative
therapy
Attachment Theory
• Explains how even healthy adults need to depend on
one another
• Attachment means seeking closeness in the face of
stress
• Infants use their attachment figure (usually their
mother) as a secure base for exploration of the world
and are able to rely on the caregiver as a source of
comfort and protection
• Attachment theory is applied to clinical treatment by
linking symptomatic expressions of fear and anger to
disturbances in attachment relationships
Concepts of Family Therapy
• Complementarity: refers to the reciprocity which is
defining feature of every relationship
• Interpersonal context: a person’s behavior is
influenced by interactions with the family
• Circular causality: accounts for communication and
relationships in explanation of causality
• Family structure: idea that families can be understood
by assessing the boundaries between various
subsystems within them
Concepts of Family Therapy
• Triangles: when two people cannot solve a
problem between themselves, they will pull in
a third party; understanding the triangular
nature expands the therapist’s lens and opens
up possibilities for intervention
• Function of the symptoms: patient’s symptoms
often has a stabilizing influence on the family
(homeostatic influence)
Concepts of Family Therapy
• Family narratives: help people identify oppressive
stories and co-create with them new, more
empowering accounts of their lives
• Culture: feminist critique in 1980s helped turn the
impact of family to culture’s attitude towards women,
people of other races, different lifestyles, and the poor
• Resistance: human systems are reluctant to make
changes they perceive as risky – families fear what
might happen if their conflicts are brought out into
the open
CHAPTER 5
The Bowen Family Systems Therapy
An Intergenerational Approach
to Family Therapy
Bowen’s Theory
• Centers around two counterbalancing/competing life
forces: togetherness and individuality (need for
companionship and the need for independence)
– First and last name
– Unbalance toward individuality leads to emotional cutoff;
unbalance toward togetherness leads to fusion
• Central premise: unresolved emotional attachment to
one’s family must be resolved before one can
differentiate a mature, healthy personality
Differentiation of Self
• Degree to which one balances emotional and intellectual
functioning and intimacy and autonomy in interpersonal
relationships
• Ability to think and reflect – to not respond automatically to
emotional pressures
• More highly differentiated individuals can experience strong
emotion, but can also shift to logical reasoning for decision
making and problem solving
• Undifferentiated individuals tend to act based on emotional
reactions
• Undifferentiated individuals find it difficult to maintain their
own autonomy
Emotional Triangles
• Emotionally significant relationships shadowed by third
parties
– Friends
– Family
• Anxiety is the driving force behind emotional triangles
• Can be temporary or fixed
• Triangulation freezes conflict in place and becomes a chronic
diversion that undermines relationships
• Most family problems are triangular
– Teaching a mother better parenting techniques won’t resolve the
problem if she is over-involved with her son as a result of her
husband’s emotional distance
Nuclear Family Emotional Process
• The emotional forces in family – excessive emotional
reactivity or fusion
• Lack of differentiation in family constrains members’
abilities to regulate emotionality and manage anxiety
• Problems can include:
– reactive distancing between spouses
– emotional dysfunction in one spouse
– marital conflict
– projection of the problems onto children
Family Projection Process
• Defined as the process by which parents transmit their lack of
differentiation to their children
• Emotional fusion in a couple leads to conflict, emotional
distance, or reciprocal over-and-under functioning
• Spouses with unresolved family-of-origin issues create a
family environment in which there is an intense focus on one
or more children
• The child who is the object of the projection process becomes
the child most attached to the parents and has the least
differentiation of self; the ability to adapt is limited because of
the intense focus of parental anxiety onto the child
Multigenerational
Transmission Process
• Defined as the family emotional process across
multiple generations
• In each generation, the child most involved in
the family’s fusion moves toward a lower level
of differentiation of self; the least involved
child moves toward a higher level of
differentiation
• Individuals at similar levels of differentiation
will seek each other out and marry one another
Multigenerational
Transmission Process
• Couples establish a new family which influences a
child’s ability to regulate emotionality
• Problems in the family are products of the
relationships with parents, which is a product of the
relationship with the parents’ parents (i.e.,
grandparents)
• Our family background catches up with us!
• Wherever you go, you take your family with you.
Sibling Position
• Children develop fixed personality characteristics
depending on sibling position in family
• Frank Sulloway (1996) – personality is the repertoire
of strategies that siblings use to compete with one
another to secure a place in the family
• Firstborns identify with power and authority, which
maximizes cost of siblings by dominating them. May
tend to be more self-confident
• Laterborns are more open to experience and may be
rebellious. More likely to identify with the oppressed
and challenge the status quo
Emotional Cutoff
• How people manage anxiety between generations
• Personified in the “reactive emotional distancer” who is
undifferentiated, yet appears independent and separate from
the family
• This person denies the importance of his/her family
– Often boasts of his/her independence from family
– Has infrequent communications with family
– Displays an exaggerated façade of independence from the
family
• Finds intimacy extremely threatening
• The family as kryptonite – people rendered helpless by their
families
Societal Emotional Process
• Emotional process in society that influences the
emotional process in families
• Background influence affecting all families
• Describes how prolonged increase in social anxiety
can result in gradual lowering of the functional level
of differentiation in families
• Monica McGoldrick and Betty Carter added gender
and ethnicity to their theory
• Challenged power imbalances and highlighted the
importance of family and cultural background
Normal Family Development
• Families vary along single continuum of differentiation, low to
high
• Optimal development when:
– Individuals are relatively differentiated
– Anxiety is low
– Parents are in good emotional contact with their families
– Family members distinguish thinking from feeling
processes and remain independent while in connection with
their nuclear and extended families
Development of Behavior Disorders
• Symptoms come when stress exceeds the
system’s ability to handle it
• Emotional fusion is the genesis of
psychological problems – based on anxious
attachments resulting in isolation or
dependence
• Family symptoms reflect:
– Level of chronic anxiety
– Level of differentiation in family system
Development of Behavior Disorders
• The more well-differentiated the person, the
more resilient and more sustaining his/her
relationships
• The less differentiated, the less stress it takes
to produce symptoms
• Undifferentiation in family leads to marital
problems in nuclear family
– Projected onto spouse or child, who then
becomes symptomatic
Goals of Therapy
• Not interested in solving problems
• Therapy is an opportunity for people to learn about
themselves so they can assume responsibility for their
problems
• Therapist helps client get past blame to examine their
own role in the family
• Goals of therapy:
– Decrease levels of anxiety; increase level of
differentiation
– Help individuals gain insight into their family-of-
origin patterns
Goals of Therapy
• Examine process and structure of therapy
– Process: patterns of emotional reactivity
– Structure: patterns of interlocking triangles
• Modify the marital system to change the family
– Increase parents’ ability to manage their own
anxiety
– Help couple have less anxiety in their family-of-
origin
Therapy
• Begins with assessment: description and history of
relationship context of problem (transitions, parents)
• Genogram: traces significant relationship patterns
(triangles, cutoffs) through at least three generations
– Assess emotional patterns and stresses endured and
adaptation
Therapy
• Change occurs as one learns about the larger family
• Typically work with couples or individuals
• If individuals, the goal is differentiation of self
• Bowen had success differentiating himself from his
own family – he became convinced that a single
highly motivated person could change an entire
family system
• Prerequisites to change: 1) knowledge of how family
systems function; 2) strong motivation to change
Therapeutic Techniques
• Process questions: encourage families to think about
how they react and respond with other family
members
– Used to slow people down, diminish reactive
anxiety
– Important to establish that even though problems
occur in a relationship context, individuals are
responsible for their own behavior
• Genograms
• Therapeutic Triangle
Therapeutic Techniques
• Relationship experiments: becoming aware of system
processes (pursuer/distancer)
• Coaching (helping increase self-focus)
• The I-Position: taking a personal stance on something instead
of focusing on what others are doing
• Multiple family therapy: working with couples taking turns
examining family backgrounds of each member
• Displacement stories: teaching family members about systems
through stories, films, videos (non-threatening)
CHAPTER 6
Strategic Family Therapy
Strategic Family Therapy
• Emerged from the Palo Alto Group in the 1950s
• Impacted the entire field of family therapy – mid ’70s
to mid ’80s
• Based on the communications model of Bateson, etc.
• Derived from general system theory and cybernetics
• Three main models:
– The Mental Research Institute (MRI) Model
– Strategic Therapy of Jay Haley and Cloe Madanes
– The Milan Systemic School
Overarching Themes
• Strategic interventions are designed to:
– Bypass resistance
– Downplay the importance of intrapsychic
processes
• Share a belief that:
– Therapy should be brief
– People aren’t pathological
– Change can occur suddenly
Leading Figures
• Overarching Figures – Milton Erickson,
Gregory Bateson, Jay Haley, Don Jackson,
Paul Watzlawick
– MRI Group (1970s and early 1980s)
• Jackson, Watzlawick
– The Washington School
• Jay Haley, Cloe Madanes (blended structural principles
and strategic techniques)
– Milan Associates
• Selvini Palazzoli, Luigi Boscolo, Guiliana Prata
Theoretical Formulations
• The hallmarks of strategic therapy are:
– Using a set of novel strategies to solve family
problems
– Generating change rather than generating insight
– Circumventing resistance rather than dealing
directly with it
Theoretical Formulations
• MRI Group (Jackson, Watzlawick)
– Based on cybernetics (1st and 2nd order change)
• Identify feedback loops that maintain problems
• Identify family rules that govern feedback loops
• Change the feedback loop or the rules of the system
• The approach is pragmatic, time-limited, and
problem-focused
Theoretical Formulations
• Strategic - Jay Haley and Cloe Madanes
– Combines aspects of structural and strategic
approaches to treating families
– Rules around the family hierarchy are crucial
– Techniques are strategic, assessment of problems
and families is structural (family’s problems are
maintained by hierarchy and boundary problems)
– Prescribing ordeals – the price for keeping the
symptom outweighs that of giving it up
(insomniacs waxing floors)
Theoretical Formulations
• Cloe Madanes added to Haley’s model
– Function-of-the-symptom (kids using symptoms in
an attempt to change parents)
– Family problems are based on four intentions: the
desire to control and dominate, to be loved, to love
and protect others, to repent and forgive
Theoretical Formulations
• Milan Systemic – Palazzoli, Prata, and
Boscolo and Cecchin
– Focus on power games in the family
– Emphasized a multi-generational perspective
– Examined covert family alliances and coalitions
across generations
– Symptoms were used to protect family members
(child’s acting out were used to protect Dad’s
alcoholism)
Normal Family Development
• MRI Group
– No one model of healthy or normal families
– Focus on eliminating the problems that families present to
them
• Strategic of Haley and Madanes
– Normalcy linked with family structure that has clear
boundaries and parents firmly in charge
– Also emphasized life-cycle stages of family
• The Milan Group
– No preconceived model of normalcy
– Maintain an attitude of neutrality and curiosity
Problem Development
• MRI Group
– Chronic problems are caused by poor solutions that
maintain the status quo or lead to feedback escalations –
solutions become problems
• Haley and Madanes
– Problems are the result of flaws in the family’s hierarchy or
boundaries, inability to resolve life transitions
• The Milan Group
– Problems are caused and maintained as people protect each
other and problems serve a function for the family system
Therapy Assessment
• MRI Group
– Carefully defining the presenting problem and figuring out
why it is perpetuated. Non-historic and symptom focused.
• Haley and Madanes
– Examine behavioral sequences around the problem
– Examine structural anomalies (weak parental hierarchies,
cross-generational coalitions)
• The Milan Group
– Preliminary hypothesis tested using circular questioning
(systemic explanations)
Therapy Techniques
• MRI Brief Therapy Center
– Find the most motivated person in the system
– Gain clear understanding of problem (symptom)
– “What will be the first signs that things are getting better”
– Inquire about attempted solutions
– Observe and interrupt problem-maintaining sequences
– Use therapeutic paradox (family encourages depressed
member to be sad so he feels less guilt for not being happy)
Therapy Techniques
• Strategic Family Therapy of Haley and
Madanes
– For therapy to “end well, it must begin properly”
– Haley joins and interviews the entire family
• Social Stage
• Problem Stage
• Interactional Stage
• Goal-Setting Stage
• Task-Oriented Stage
– Use of Directives
Therapy Techniques
• Milan Systemic:
– Pre-session, Session, Intersession, Intervention, Post-
session discussion
• Positive connotation (reframing without blaming)
• Rituals (exaggerated family rules and myths)
• Circular questioning
• Team approach (reflecting team, Greek chorus)
• Neutrality
Haley
Stages of the First Interview: The Social Stage
• Each family member should speak and
introduce themselves
• The therapist should ensure that problems are
not to be discussed until everyone has had a
chance to speak
• Therapist should examine family seating
arrangements to assess family organization
• Keep conclusions tentative
Haley
Stages of the First Interview: The Problem Stage
• Shift to the therapy stage
• Inquire why the family is there and what the problem
is
• Be general and ambiguous so the family can expand
• Respect the family hierarchy to gain cooperation
• Treat those who have power and influence in the
family with respect so they can bring family back
• Therapist should not share observations with the
family
• Therapist should think of the problems in terms of
more than one person
Haley
Stages of the First Interview:
The Interaction Stage
• It is critical that family members interact with
one another rather than with the therapist at
this stage
• Therapist should redirect family members
toward each other if they attempt to engage
him or her
• Assess family organization through
interactions
– Cross generational alliances, etc.
Haley
Stages of the First Interview:
The Goal- and Task-Setting Stages
• Goal-Setting Stage
– Families need to define desired changes
– Therapist can act as wise advisor and assist the
family in setting goals
• Task-Setting Stages (Directives)
– Use of directives (thoughtful interventions aimed
at targeting and changing specific behaviors)
CHAPTER 7
Structural Family Therapy
Structural Family Therapy
• Regarded as one of the most influential and
widely used therapies used in the field
• Founded by Salvador Minuchin
– Born and raised in Argentina
– Psychoanalytically trained child psychiatrist
– Worked with inner city families
– Developed an approach to work with chaotic
family structures
– Directed the Philadelphia Child Guidance Clinic
Overarching Themes
• Structural Family Therapy is comprised of
various components and themes including:
– Family Structure
– Family Subsystems
– Family Boundaries
Family Structure
• Structure – predictable sequences or organized
pattern in which families interact
• Structure – a set of rules governing behavior patterns
– Once patterns are established, family members use a small
range of behaviors available to them (patterns and roles are
set and assigned)
– Once patterns are set, this leads to predictability in behavior
sequences
• Structures typically have some form of hierarchical
structure and also tend to have reciprocal and
complementary functions (parental involvement with
children, over vs. under involved)
Family Subsystems
• Subsystem – Members of a family who join together
to perform various tasks
• Subsystems can include parents (executive
subsystem), parent/child, child/child
• Subsystems are often formed based on the patterns of
interaction in a family
• Patterns of interaction are largely based on family
roles and rules
• Covert coalitions are often more significant than
obvious groupings
Boundaries
• Emotional barriers that serve to protect the
separateness and autonomy of the family
• Rigid boundaries – overly restrictive and permit little
contact with other systems resulting in disengagement
– Disengagement promotes independence but limits warmth
and affection
• Diffuse boundaries – offer heightened amounts of
mutual support, but at the expense of independence
resulting in enmeshment
– Enmeshment promotes dependence and limits contact with
others outside the family system
Normal Family Development
• Healthy families are not defined by the absence of problems,
but rather by a functional family structure
• Healthy families can modify their structure to accommodate
changing circumstances (development)
• Unhealthy families increase rigidity of structures that are no
longer functional
• When people marry, they are to accommodate each other and
negotiate boundaries between them
• When children are born, families should establish an executive
parental sub-system and sibling sub-system.
• As children grow, families must make changes to the family
structure to accommodate development
Development of Behavior Disorders
• Healthy families accommodate change
• Less adaptive families increase rigidity of
structures and are no longer functional
• Enmeshed families
– Boundaries are diffuse
– Family members become dependent on one
another
Development of
Behavior Disorders
• What creates problems within families?
– Weak hierarchies
– Conflict avoidance
– Cross-generational coalitions
• Problems arise in families when…
– family structures are inflexible
– they fail to adjust to changing circumstances
– they fail to reorganize themselves in order to deal
with the stresses in the home environment
Goals of Therapy
• The ultimate goal of therapy is structural changes to
the family (roles, rules, hierarchy, behavior patterns)
• Alter the family structure so that the family can solve
its own problems (uniqueness of each family)
• General goal: create or strengthen executive
subsystem
• Enmeshed families: create more appropriate
boundaries between individuals and subsystems
• Disengaged families: increase interaction by making
boundaries more permeable
Therapy
• Therapy should begin with an assessment in which the
entire family is interviewed and patterns of behavior
are observed (e.g., enmeshment and disengagement)
• Therapists have two types of assessment tools:
– enactments
– spontaneous behavior sequences
• Enactments occur when a therapist stimulates a family to
demonstrate how they handle problems
• Therapists guide the family how to modify the enactment, creating
new options for behavior sequences
Therapy: Phase I
• Opening Phase:
– Joining and accommodating – obtaining acceptance from
the family in order to disarm defenses and create an
environment for change (effective therapy requires
challenge and confrontation)
– Working with interaction (use of enactments – dialogues
and playful or disciplinary interaction with children in
order to observe how families relate to one another)
– Mapping structural patterns (observing enmeshment and
disengagement)
Therapy: Phase II
• Focus on the underlying family structure
– Highlight and modify interactions
– Intensity (interrupt rigid and difficult patterns)
– Help people do things themselves
– Therapists can invite family members to
participate and interact in ways that will help them
function more effectively
Therapy: Phase III
• Transformation of Family Structure
– Boundary Making
• Loosen boundaries in disengaged families
• Strengthen boundaries in enmeshed families
– Unbalancing (change the relationship of family
members within a subsystem by joining a
subsystem or individual at the expense of another –
taking sides)
– Reframing (adding cognitive constructions)
Evaluating Therapy,
Theory, and Results
• Strong empirical support for effectiveness
– Psychosomatic children are used to regulate stress
between the parents
– Effective in treating anorexia, psychosomatic
asthma, drug addiction in families, ADHD, and
conduct disorders
CHAPTER 8
Experiential Family Therapy
Experiential Family Therapy
• Family therapy as an emotional encounter
– Emerged from the humanistic branch of
psychology
– Focuses on the “here and now experience”
– Focuses on emotional experience
– Emphasized individuals and their emotions
– Began with Whitaker and Satir
– Reemerged with Johnson’s EFT and Schwartz’s
IFS
Sketches of Leading Figures
• Carl Whitaker
– OBGYN and psychiatrist
– Intuitive approach; among the first to conduct
therapy with families
– Believed in connecting individuals and families
– Known as a maverick, but admired
– Not bound by social convention
– The Hindrance of Theory in Clinical Work (1976)
– Died in 1995
Sketches of Leading Figures
• Virginia Satir
– Associated with the MRI group 1959-1966
– Highly nurturing, empathetic, and genuine
– Used techniques of touch and sculpting
– Very popular presenter at conferences – worked
with families and influenced entire audiences
– Stressed the importance of good communication
among family members
– Died of cancer in 1988
Theoretical Formulations
• Family difficulties and problems are caused by
emotional suppression
– Parents regulate and control children’s feelings
– Children suppress or blunt their emotional
experience
– Dysfunctional families are not tolerant of emotions
– Children grow up estranged from themselves
– Change families by getting in touch with emotions
– hopes/desires and fears/anxieties
Theoretical Formulations
• Grew out of existential psychology
– Developed in response to perceived limitations in
psychoanalysis and behaviorism
– Emphasized freedom and the immediacy of
experience
– Individual experience is valued over family
structure
– Needs of the family “follow on the heels of
individual enhancement”
Theoretical Formulations
• Techniques are aimed at promoting
communication and interaction
• Opening up the individual to new experiences
is a prerequisite to changing the family
• Liberate affect and impulses to promote
individual growth and family cohesion
• Exception is emotionally focused couples
therapy
Normal Family Development
• Healthy families support individual growth in family
members and permit a wide range of experiencing
• Family members are secure and honest about their
feelings and they feel free to express them
• Dysfunctional families resist awareness and limit
emotional expressiveness
• Open, spontaneous experiencing is considered the
most important aspect for healthy family functioning
Problem Development
• Symptoms result when feelings are suppressed and
impulses are denied
• Suppressing emotions robs family members of their
flexibility and vitality
• Satir spoke of families living in quiet desperation
• Four types of destructive communication can smother
feelings:
– blaming
– placating
– being irrelevant
– being ultra reasonable, promoting inauthentic
communication which is rooted in low self-esteem
Goals of Therapy
• Promote individual and family growth through
experience and emotional expression
• Increase personal integrity (feelings and behaviors are
more congruent)
• Liberating the affect and impulses of family
members, thereby enhancing growth and self-
awareness
• Revitalize family relationships through family
members who act more like themselves
• Bring the family together emotionally to develop a
sense of belonging and freedom
Therapy Techniques
• Assessment
– Pay less attention to assessment than any other
school of family therapy
– Avoid characterizing people
– Do not favor diagnostic categories
– Seek to understand the defenses that keep people
from experiencing their full range of emotions and
feelings
Therapy Techniques
• Create personal therapeutic encounters by
using structured exercises and techniques
• Two groups:
– One group uses highly structured devices such as
family sculpting, role playing, family art therapy,
conjoint family drawing, and Gestalt therapy
techniques to promote affective expression
– The second group uses the force of their own
personalities, personal spontaneity, and creativity
(Whitaker, Satir)
Therapy Techniques
• Sculpting – Therapist asks a family member to
physically arrange the family to represent family
roles, rules, and perceptions of family members
• Family art drawing and conjoint therapy are used to
help the family express themselves in ways that tap
into emotions
• Role playing – reenact scenes from childhood or
present
• Psychology of the absurd – taking clients’ statements
to the extreme “I can’t stand my husband” “Why
don’t you get rid of him or take up a boyfriend”
Therapist’s Role
• Must be a genuine person who can bring about
change
• Does not hide behind a professional role
• Must be caring and accepting
• Must be open and highly active
• Must be emotionally in touch with their own
experiences and pay attention to
countertransference
Experiential Family Therapy Today
• Emotionally Focused Couples Therapy – Johnson
– Based in attachment theory – 9 step process
– Received empirical support
• Internal Family Systems – Schwartz
– People in contact with each other are usually in conflict
with themselves
– Conflicting inner voices are personified as parts
– Underneath people’s emotionally reactive parts lies a
healthy self at the core of the personality
CHAPTER 9
Psychoanalytic Family Therapy
Rediscovering Psychodynamics
• Most family therapists rejected the
psychoanalytical model when it came to
working with families
• Family therapy rediscovered psychoanalytic
theory in the 1980s
– Object relations theory and self psychology more
conducive to family therapists
Leading Figures
• Freud
– designed therapy that focused on the individual,
deliberately excluded family
• Melanie Klein, Ronald Fairbairn, and Donald
Winnicott
– concentrated on the nature of interpersonal relationships
• Henry Stack Sullivan and Edith Jacobson
– emphasized interpersonal relationships
• Henry Dicks
– first to apply object relations theory to treatment of marital
conflict
Object Relation Theory
• Focuses on interpersonal relationships
• Bridges gap between psychoanalysis and
family therapy
• Selfhood and identity are formed and
maintained through relationships in past and
present
– We relate to people in the present based on early
experiences with primary caregivers
– “Internal objects” form the core of our selves
Normal Family Development
• Draws from objects relations theory, attachment
theory, and theories of the self
• Process of growth depends on the ego’s relations with
objects
– First as actual interactions with real objects, later as
unconscious residues of those early interactions
• Reliable and loving support creates a successful
completion of separation-individuation
• Good-enough mothering enables children to achieve a
sense of identity
Normal Family Development
• Two necessary qualities of parenting for a secure and
cohesive self: empathy and offer a model of
idealization
• Boszormenyi-Nagy believed relational ethics to be a
fundamental force that holds family and societal
relationships together
• Psychoanalytic perspective: family development
depends on the early development of the individual
personalities that make up the family
– If spouses are mature and healthy adults, family will be
harmonious
Development of Behavior Disorders
• Poor adult adjustment is a result of inadequate
separation – parents’ failure to accept their children
as separate beings can take extreme forms
– Theorists believe that anorexia nervosa results from
inadequate separation and individuation
• Failure to develop a cohesive sense of self and a
differentiated identity causes intense emotional
attachment to the family
– Handicaps a person’s ability to develop a social and family
life of his own
Behavior Disorders
• One’s choice of marital partners is based
partially on the desire to find someone who
will complement and reinforce unconscious
fantasies
• Marital choice also affected by false-self
phenomenon
– False-self develops in insecurely attached children,
where they learn to hide their needs and feelings to
win approval
Goals of Therapy
• Goal of psychoanalytic therapy is intrapsychic
restructuring or personality change
• Family members are freed of unconscious
restrictions
• Individual family members are helped to
reintegrate split-off parts of themselves in
order to become fully integrated or cohesive
Therapy
• Assessment
– after the roots of the current family conflict have
been uncovered, interpretations are made about
how family members reenact past
• Techniques
– therapist employs four basic techniques to foster
insight and facilitate process of working through:
listening, empathy, interpretation, and analytic
neutrality
CHAPTER 10
Cognitive-Behavioral Family Therapy
Overarching Themes
• Behavior therapists first began working with families
in the 1970s.
• Behavior therapy was based on learning theories and
was aimed at parent training and couple
communication
• Was limited in its approach to families because it
often did not take into account the complicated nature
of family systems
• The approach is now making changes to be more
adaptive to the complex systems imbedded in families
Leading Figures
• Ivan Pavolv – Classical conditioning
– Unconditioned stimulus (UCS) – food
– Unconditioned response (UCR) – salivation
– Conditioned stimulus (CS) – ringing bell
• Joseph Wolpe – Systematic desensitization
– Anxiety is acquired through classical conditioning
– De-conditions anxiety through reciprocal inhibition
• Reciprocal inhibition – pairing responses incompatible with anxiety
to the previously anxiety-arousing stimuli (muscle relaxation,
visual imagery, etc).
Leading Figures
• B.F. Skinner – Operant conditioning
– Responses that are positively reinforced will be repeated
more frequently
– Behaviors that are punished or ignored will be reduced or
extinguished
• Gerald Patterson – Developed behavioral parent
training
• Robert Liebermann – Behavioral approaches to
couples and family therapy
• Albert Ellis (1962) and Aaron Beck (1976)
introduced cognitive elements into behavioral therapy
Theoretical Formulations
• Behavior is maintained by its consequences
• Behavioral problems are caused by
dysfunctional patterns of reinforcement
between parents and children
• Behavior will remain resistant to change until
more rewarding consequences are introduced
• Social exchange theory – people strive to
maximize rewards and minimize costs in
relationships (key for couple relationships)
Theoretical Formulations
• Behavioral approaches are typically limited to two
party relationships (parent/child, spouses). Fail to
take into account the triadic nature of relationships
• Cognitive theorists emphasized the need for attitude
changes to promote and maintain behavior change
• Cognitive techniques became more prominent as
behavior therapists realized an exclusive focus on
behavior often failed to address the complicated
dynamics of couple and family interaction
Normal Family Development
• Healthy families are those in which positive
behaviors are maintained by appropriate
consequences and negative behaviors are
extinguished through the use of punishment
• Healthy families have high ratios of benefits to costs
• Healthy couples will be able to engage in effective
communication skills, problem-solving skills, and
conflict resolution
• Healthy families and couples have the ability to
adapt, be flexible, and change
Development of Behavior Disorders
• Behavioral Family Therapy
– Symptoms are viewed as learned responses
– For behavioral therapists, no underlying meanings of
symptoms are sought
– Attention is focused on the symptoms themselves and the
environmental responses that reinforce the behavior
• Cognitive-behavioral therapists will include ideas
about dysfunctional schemas regarding family roles
and relationships that are learned in one’s family-of-
origin
– Cognitive Distortions (8 types).
Goals of Therapy
• Behavioral and cognitive changes in the way one
behaves toward and thinks about the family
• Increase the rate of rewarding interactions in family
relationships
• Decrease the use of negative family interactions;
increase positive interaction
• Teach effective communication and problem-solving
skills
• Alter negative thought patterns that promote or
maintain ineffective family interactions
Therapy Assessment
• A hallmark of behavioral therapy
• Evaluations created by defining, observing, and
recording the frequency of the behavior to be
modified
• Careful assessments are conducted to determine the
contingencies of reinforcement
• Families and couples – questionnaires and home
observations are conducted.
– For sex therapy, clinical interviews are the main assessment
tool
Therapy: Behavioral Parent Training
• Treatment goals are set based on results of
assessment
• Behavioral Parent Training
– Techniques for child and adolescent patients are based on
operant conditioning and include:
• Shaping (reinforcing change in small steps)
• Token economies (point systems, rewards)
• Contingency contracting (parents will make changes once they see
changes in children)
• Time-out (ignoring or isolating the child following unwanted
behavior)
Therapy: Behavioral Couples Therapy
• Assessment through the use of standardized measures
• Therapist helps couple accept mutual responsibility
and mutual possibility for change
– Behavioral interventions
• Make lists of things that occur during week
• Behavior exchange
• Conflict engagement
• Quid pro quo contracts
• Problem-solving training
Therapy:
Cognitive-Behavioral Approach
• Cognitive inferences are believed to evoke emotion
and behavior (cognitive schema related to family-of-
origin and families in general)
• Clients learn to recognize automatic thoughts by the
use of thought records and diary keeping. Therapists
challenge or attempt to change these beliefs to make
them more functional.
• Addresses the limitation in previous behavioral
theories that took a highly linear approach to family
behavior
Therapy:
Cognitive-Behavioral Approach
• This approach shows much promise when working
with couples and families
• Balances the emphasis on cognition and behavior
• Focusing in greater depth on family interaction and
patterns
• Overcoming the limitations of past linear / behavioral
models as family relationships, cognitions, emotions,
and behaviors are thought to exert mutual influence
on one another
CHAPTER 11
Family Therapy in the Twenty-First Century
Family Therapy Today
• Field is no longer divided into separate schools
• Postmodernism gave rise to…
– a lack of absolute truth
– desire to merge some schools of family therapy
together
• Need for individualized techniques to deal
with certain problems and populations
Feminist Family Therapy
• Exposed gender bias in family therapy
• Equal responsibility
• Help women and men re-examine gender roles
that keep women from realizing their full
potential
• Uses existing forms of family therapy (e.g.,
Bowenian, solution-focused) as primary
treatment
– Adds in a sensitivity to gender
Social Constructivism
and Narrative Therapy
• Social Constructivism • Narrative Therapy
– Explores perspectives – How experience creates
– Doesn’t focus on expectations
patterns of interaction – How expectations form
– Social constructionism our self concept
adds element of
interaction
Issues in Family Therapy
• Family Violence
– Domestic violence is a major public health
problem
• Multiculturalism
– Requires ethnic sensitivity and respect
• Race
– Requires understanding of reluctance to engage in
treatment
– Must face personal attitudes about race, class, and
poverty
Issues in Family Therapy
• Poverty and Social Class
– Understand implications of being “poor” in the
United States
• Gay and Lesbian Rights
– Understand struggles and unique issues
• Spirituality
– Can be source of family’s most powerful beliefs
– Explore without judgment
Treatment: Single-Parent Families
• Goals • Treatment involves…
– Strengthen hierarchical – Addressing the
position in relation to presenting complaint
child(ren) – Helping parent take more
– Become more fulfilled in effective charge of
parent’s own life child(ren)
– Increasing sources of
support
Treatment: African-American Families
• “Family” includes • Recognize
kinship network – Enmeshment with
– Search for areas of community (e.g., church,
strength school)
– Enlist support in helping – Potential anger caused
family by decades of racism
– Importance of religion
and spirituality
– Importance of a possible
absent father
Treatment: Gay and Lesbian Families
• Unique challenges • Probe for signs of belief in
– Homophobia cultural stereotypes
– Relational ambiguities (including instability)
– Developing support • Requires sensitivity to
issues of:
– Extreme jealousy
– Anger
– Coming out (to family)
• Create atmosphere of safety
to explore any shame about
their needs for affection or
intimacy
Newer Family Therapies
• Psychoeducational • Medical Family
Family Therapy Therapy
– Establishes collaborative – Preparation for dealing
partnership with illness
– Support and – Gain perspective on
Empowerment effects
• Achieved by… – Examine available
– Removing blame resources
– Reinforcing family
strengths
– Sharing information
CHAPTER 12
Solution-Focused Family Therapy
Leading Figures
• Steve de Shazer
– Milwaukee, WI
– 1979: Started the Brief Family Therapy Center (BFTC)
– Worked in Palo Alto; influenced by MRI
– Focuses on solutions that work rather than solutions that do
not work as in the MRI model
• Insoo Berg
– BFTC
– Applied the model to alcoholism, marital therapy, and
family-based services to the poor
Theoretical Formulations
• Derived from MRI
• Focus on cognitions rather than behavior
• Focus on presenting the problem
– Find the simplest solution
• Focus on exceptions
– Exceptions to client’s problem are the solution
• Assumes people are capable of behaving effectively,
but are blocked by negative mindset
• People already have the solution(s) to their problems
Theoretical Formulations
• Look to future where problems can be solved
• People constrained by narrow view of their
problems
– Rigid patterns of false solutions
• People attempt to fit their stories into their
existing schemas and societal expectations
• Language shapes reality
Normal Family Development
• Avoid judgments about “what is normal”
• Clients assumed to be experts on their own
situations
• Interest in language
– How people describe themselves
– How people describe their problem(s)
• Focus on complaints presented
– Should not impose values by suggesting clients
address other un-presented problems
Development of Behavior Disorders
• Solutions to problems are unrelated to the
development of the problem
• Tracking the development of the problem
should be avoided
• Problem-focused thinking prevents effective
solutions from being recognized
Goals of Therapy
• Resolve presenting complaint by helping
clients do or think differently
• Trust clients to reach their own goals
• Help clients identify the problem-solving skills
they have lost sight of
• Help clients locate their resources
Conditions for Behavior Change
• Amplify exceptions to their problems –
effective solutions that are already in their
possession
• Construction of solution-oriented narratives
• Therapist and client engage in a discussion that
shifts the language of the problem
• Encourage positive talk which will lead to
positive thinking and positive problem solving
Therapy Assessment
• Very little intake information
• Avoid any assessment of how problems
develop
• Concentrate on assessing future goals
• Therapy should only include people concerned
about the problem
• Hear the client’s constructions of their
problems without preconceptions
Therapeutic Techniques
• Problem Description
– Ask clients to describe their problem
– Ask how they have tried to resolve these difficulties
• Goal Setting/Miracle Question
– Activates problem-solving mindset by giving people a
vision of their goal
• Exploring Exceptions/Exception Question
– Directs clients’ attention to times when they did not have
the problem
– What they can do to expand the exceptions
Therapeutic Techniques
• Scaling Questions
– Help therapist and clients talk about vague topics (e.g.,
depression)
• On a scale from 1 to 10, how sad do you feel?
• Coping questions
– How have you coped in the past?
• Compliments
– Brings attention to the fact that the client has already done
something
• Later sessions are devoted to measuring progress
CHAPTER 13
Narrative Therapy
Leading Figures
• Michael White
– Adelaide, Australia
– Dulwich Centre Newsletter
– Interested in how problems afflict people
– Problems happen to people; they are not part of people
• David Epston
– Maintenance new narrative through supportive
communities
• Self-help “leagues”
– Writing letters to continue the clients’ new story
Theoretical Formulations
• Goal
– Shift from historical truth to narrative viability
• People attempt to fit their stories into their existing
schemas and social expectations
– Experiences that don’t fit are distorted to fit
• Problems arise because people are indoctrinated into
narrow and self-defeating views of self and the world
• Life stories function as filters
– Screen out/distort experiences that don’t fit our plotlines
Normal Family Development
• Avoid judgments about what is normal
• Avoid categorizing
• Avoid the idea of general principles of what
causes problems or what resolves them
Basic Assumptions
• People have good intentions; they do not need
or want problems
• People are profoundly influenced by the
disclosures around them
• People are not the problem, the problem is the
problem
• People can develop alternative empowering
stories once separated from their problems
Development of Behavior Problems
• The stories people tell themselves lead them to
interpret their experience in unhelpful ways
• Patterns of tunnel vision
• Problem-saturated stories take hold and
encourage people to respond to each other in
ways that perpetuate the problem story
• Emotional responses are a result of toxic
effects of cultural narratives that govern lives
Goals of Therapy
• Separate the problem-saturated stories to open
space for new and more constructive views of
themselves
• Look for unique outcomes
– “Sparkling events”
Conditions of Behavior Change
• Deconstruction
– View problem as an external entity to start challenging its
influence
• Unique Outcomes
– Resistance to the problem’s influence
– Opens room for counter stories
• Opens room for “counterplots”
• Shift family member views of each other from
“totalizing views” that lead to polarization and
antagonism
Therapy Assessment
• Obtain the family’s story, their experience, and
assumptions about the problem
• Map the influence of the problem on the
family and map the influence of the family
over the problem
• Move clients toward knowing that they already
have some power over their problems
Therapeutic Techniques
• Interventions are done in the form of questions,
paying special attention to talents and strengths
• Deconstruction
– Ask clients to tell their problem-saturated story
– Ask questions that externalize the problem
• Relative influence questions
– How the problem has disrupted or dominated the family
• Opening Space Questions
– Uncovering unique outcomes
Therapeutic Techniques
• Preference Questions
– Make sure unique outcomes represent preferred outcomes
• Story Development Questions
– Develop stories from the underpinnings of the preferred
unique outcomes
• Meaning Questions
– Challenge negative images of self and emphasize positive
agency
• Questions to extend the problem into the future –
supporting changes and reinforcing positive
developments
CHAPTER 14
Integrative Models
Integrative Therapy
• No single approach has proven most effective
• Argues that human beings are complicated and that
therapy must impact all different dimensions
• Described as a respect for the multiplicity of truth
• Refers to eclecticism, selective borrowing, and
specially designed integrative models
Eclecticism
• Draws from a variety of models and methods
• Creates a workable integration by avoiding
– Sampling techniques from diverse approaches
without focus: creates clinical inconsistency
– Switching horses midstream: becoming stuck is a
signal that you are getting to the heart of the
client’s problem
Selective Borrowing
• Adopts ideas from other models but holds on to the
core of an original theory
• Requires a solid foundation in one school of therapy
and uses a few techniques from other approaches
• Effective if used in a way that fits into your approach
– Example: Structural therapist uses the narrative
technique of externalizing the problem
Comprehensive, Theoretically
Inclusive Models
• Advantage: Address a wider range of human
experience and offer more treatment options
• Disadvantage: Require therapists to understand
multiple schools of thought
– Metaframeworks Model: Six core domains of
human functioning and releasing the constraints
that keep a family from solving its problems
– Integrative Problem-Centered Therapy:
Incorporates individual and family therapy in a
sequence
Models That Combine Two Distinct
Approaches
• Used when one approach is too limiting
– Narrative Solutions Approach: Combines the MRI
model with narrative techniques (e.g., preferred
view, posing mystery questions, and discussing the
future)
– Integrative Couples Therapy: Adds the element of
acceptance to traditional behavioral couples
therapy while emphasizing support and empathy
Models Designed for Specific Clinical
Problems
• Represented a change from focusing on generic
families to focusing on specific problems
• Example includes working with family violence
– Held that both partners were responsible for the
violence
– Works with couples but maintains that violence is
the problem
– Also incorporates an active listening format
Community Family Therapy
• Derived by Ramon Rajono in response to family
therapy’s limits with poor families
• Greatest obstacle poor people face is a sense of
powerlessness
• Treatment involves reconnecting families to their
community (e.g., obtaining health care, jobs, food
stamps, and housing)
• Integrates family therapy with community
psychology and social work
CHAPTER 15
Comparative Analysis
Theoretical Formulations
• Families as Systems
– Emphasis on how families function together and the
thinking of its members
• Stability and Change
– Families are both homeostatic and changing
– Newer approaches elicit families’ resources
• Process/Content
– Focus on process over content
– Newer models move away from process and de-emphasize
the system
Theoretical Formulations
• Monadic, Dyadic, or Triadic Model
– Monadic: The symptomatic individual is the
problem
– Dyadic: Two people in a relationship define the
actions of one another
– Triadic: Relationships between two people are a
function of relationships with a third person
• The Nuclear Family in Context
– The family is an open system where members
interact with each other and with outside systems
The Person as Political
• Family therapy believes therapists should stand for
some things and against others (i.e., serving as a
cheering squad and helping people question values)
• Boundaries
– Bowen: continuum from fusion to differentiation;
success is measured by level of differentiation
– Minuchin: diffuse and rigid boundaries with
resulting enmeshment or disengagement; success
is measured by the positive functioning of the
family
Normal Family Development
• A distinguishing characteristic of family therapy is
the focus on here-and-now interactions
• Most schools don’t have a model of what a family
should look like
– Instead they work on specific problems
• The most useful ideas of basic family functioning are
structural hierarchy, effective communication, and
family life-cycle development
Development of Behavior Disorders
• Family therapists focus on how families perpetuate
problems (not the cause of the problem)
• The Function of Symptoms: IP detours conflict and
thus stabilizes the family
• Underlying Dynamics: Focusing on behavioral
interactions is sufficient for treatment
• Pathologic Triangles: When two people are in
conflict, the one who experiences the most anxiety
will bring in a third person for support
Goals of Therapy
• Psychotherapy: Help people change to relieve distress
• Structural: Symptom resolution and structural change
• Narrative/Communication/Experiential: Improvement
of symptoms and family reorganization
• Strategic/Solution Focused: Resolve the complaint
that is presented
Conditions for Behavior Change
• Action and insight are the primary vehicles of change
– Action: People don’t change even though they
know they should (Strategic and Behavioral)
– Insight: If people understand themselves better,
they’ll be free to act in their own best interests
(Psychoanalytic and Narrative)
• Resistance
– Confronting (Structural, Experiential) versus
ignoring resistance (Behavioral)
Therapy
• Assessment
– Concentration on the whole family (Milan, Structural,
Bowenian)
– Concentration on individuals (Psychoanalytic, Experiential)
– Concentration on patterns (Strategic, Behavioral)
– No attention to what causes problems (Solution-focused,
Narrative)
• Decisive Interventions
– Family therapists use a wide variety, dictated by their
model and their personalities
CHAPTER 16
Research on Family Intervention Family Treatment
and Intervention Programs
Family-Focused Interventions
• Includes the methods used over the past few decades
to work with families
• Characterized in terms of their emphasis on
prevention, treatment and care, or by their
participants
– Patients with diagnosable psychopathology
– Children with behavior/conduct problems
– Troubled marriages
– Families faced with challenges
Scientific Methods
• Test the effects of a variety of family-focused interventions
– Specify the intervention
• Ensure that all activities are carried out in similar ways for all
families
– Choose the sample
• Use the presence of a single condition as the criterion for including
families
– Choose the comparison condition
• Include a comparison group
– Assign the condition
• Use random assignment
– Measure the outcomes
• Measures targeted outcomes (e.g., aggressive behavior, depression)
Family Interventions
for Individual Disorder
• Child and Adolescent Disorders
– Externalizing: Family therapy has been proved effective for
ADHD, aggression, and substance abuse
– Internalizing: Mixed findings concerning effectiveness
(e.g, anxiety, depression)
• Adult Disorders
– Depression: Couples therapy can be effective
– Substance Abuse: Spousal involvement can increase
sobriety and is effective in the short term
– Major Mental Illness: Provides resources for long-term
care
Family Interventions
for Relationship Disorders
• Disorders of Attachment:
– Generally effective in improving both maternal sensitivity
and child attachment
• Child Maltreatment:
– More research is needed on parent training programs
– Proactive and home visit interventions show effectiveness
• Couples Conflict:
– Behavioral and emotionally focused therapy shows
preliminary effectiveness
Programs to Help Families Make
Normative Developmental Transitions
• Marriage/Long-term Commitment:
– Programs were effective in improving how couples
communicated and managed conflict, and how they felt
about the overall relationship
• Birth of a Child:
– Couples who went through treatment reported higher
continuing satisfaction and better communication
• Transition to School:
– Programs had a positive impact on functioning (school and
emotional) before and after the transition
Programs Helping Families Cope
with Severe Stress or Adversity
• Divorce: No current studies on interventions used; positive
effects for mediation
• Remarriage/Stepparenting: Reduces child behavior problems
and couples’ conflict
• Later-Life Burden of Care: Positive results for short-term and
skill-building, but not for caretaker depression
• Palliative and End-of-Life Care: Little evidence for positive
effects other than modest for depression and patient quality of
life
• Loss and Bereavement: Program led to improved parenting,
coping, and caregiver mental health
Family Intervention Process Research
• Process Research Methods: Employ direct
observation to describe therapists’ activities and their
effects (e.g., reframing, enactment, supportiveness,
defensiveness)
• The Therapeutic Alliance: Clinically important
findings reveal the importance of the alliance in
therapy (therapist-client and client-client alliance)
• Critical Events and Change Points: Focal events
during therapy that create significant changes (e.g.,
periods of sustained engagement, facilitation of self-
disclosure, enactment, establishment of goals)