Introduction

Family therapy represents a major conceptual shift in the approach to understanding and treatment of psychological disturbance and mental illness. Within this approach symptoms are understood as the consequence of disturbance in the functioning of the family as a whole, expressed by the individual with the manifest difficulty. An understanding of how the identified patient and family affect each other both positively and negatively can lead to effective family interventions.

This chapter will introduce the development of key ideas and schools of thought within family therapy as a treatment approach. The history of family therapy provides a fascinating mirror for changes in society; the emergence of different theoretical models and treatment techniques within it reflects changes in attitudes towards what constitutes a family, with a greater recognition of diversity and cultural variation, as well as revealing assumptions and value systems which need to be challenged as society continues to evolve and to change.

The main theoretical framework is referred to as systemic theory. This is also applicable as a model in mental health care more widely, due to its focus on the system as the whole and its understanding of the wider context within which psychological disturbance occurs. This chapter will end with a consideration of how systemic thinking is helpfully applied within psychiatric practice.

The Origins of Family Therapy

In the 1930s Alfred Adler, an Austrian doctor and psychotherapist, whose ideas diverged from Freud developed Individual Psychology, and saw children with their parents for the first time. In the early stages of family therapy, the theoretical model was largely based on psychoanalytical approaches and was driven by ideas about families having potentially pathogenic influences on individual members. In the late 1950s, pathological family functioning was suspected to be linked to schizophrenia. This focus generated a body of research looking at family interactions, and communication.

A key contributor in the history of family therapy was Gregory Bateson, an anthropologist and social scientist. In 1956 Bateson introduced the term ‘double blind’ communication, a term which refers to a contradiction between the different types of communications given out at the same time [1]. ‘Digital’ communication (verbal or written) may contradict with ‘analogical’ communication (non-verbal, gestures, tone of voice, facial expression etc.). A much-quoted example is of a mother who visits her son with schizophrenia in a hospital. He is glad to see her and puts his arm around her shoulders, in response to which she physically stiffens. Noticing this, he withdraws his arm at which point she asks, ‘Don’t you love me anymore?’ When he then blushes, she says ‘You must not get embarrassed and don’t be afraid of your feelings.’ The first bind in this example concerns the son’s inability to confront his mother. The second bind is that the son is trapped by his dependence which prevents him from distancing himself from his mother. The contradictory nature of the mother’s responses means that a coherent response or resolution is impossible. Prolonged exposure to this dilemma was considered to be associated with the development of psychosis.

A related idea was that of the schizophrenogenic mother [2], in which a mixture of maternal overprotectiveness and domination was seen as evidence of how the mother’s own psychopathology could ‘drive healthy children mad’. This also illustrated how these early theoreticians came to be seen as potentially blaming family members for the disturbance in their children.

A plethora of further ideas and new terms to describe them emerged; Lyman Wynne described psuedomutuality [3], that is families presenting with a facade of unity which ignored conflict and prohibited individual separation. Psuedohostility referred to a superficial alienation of family members that masked their needs of intimacy and affection. Theodore and Ruth Lidz in 1957 described ‘marital schism’ where parents showed overt hostility but remained married because of pathological interdependence. In ‘marital skew’, the conflicts and hostilities were hidden [4, 5].

Murray Bowen, a psychiatrist and major family theoretician in the 1970s, emphasised the importance of the differentiation of self from the ‘families undifferentiated ego mass’ for psychological health and individual development. Excessive emotional interdependence, called emotional fusion, led to a poor differentiation of the self. Poorly differentiated parents raised poorly differentiated children. Bowen stated that unresolved problems were transmitted to the next generation through a process of multigenerational transmission. A person with a well-differentiated ‘self’ is able to have realistic dependence on others, and can handle conflict, criticism and rejection. Bowen also developed the idea of a Genogram representing three generations of family members and their relationship patterns pictorially (see below) [6, 7]. Genograms can show triangles (three person systems), historic and current emotional cut-offs and problematic patterns such as abuse, alcoholism over generations. Genograms continue to be used as helpful tools for mapping family relationships within a range of treatment approaches.

Systemic Family Therapies

In the 1960s families began to be conceptualised as complex systems. The term ‘systems’ refers to complex interrelated and interacting elements which are organised hierarchically. The system can vary from simple to very complex depending on the number of elements and their organisation.

To function in a coordinated way, the system needs to have control and feedback mechanisms. Cybernetics and general system theory help to understand the interactions. Cybernetics, a term coined by the mathematician Norbert Wiener, is the study of the self-corrective feedback mechanisms in complex systems including both mechanical and social systems. General System Theory (GST) was developed by the biologist, Ludwig von Bertalanffy to describe self-regulation through feedback in the living organism (e.g. levels of glucose, temperature control etc.) [8].

This idea that the family is a system governed by cybernetic principles was taken up by influential writings of Gregory Bateson. Some of the implications of Cybernetic/Systemic model are listed below.

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   1. The whole is more than the sum of its parts: each part can only be understood in the context of the whole and change in any part of the system will affect other parts

   
   
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   2. The family, as a cybernetic system is governed by its own organising rules and norms. The rules and norms are formed by all members based on their shared stories and beliefs about the family and not by any one individual. There is a tendency for stability and balance, that is, homeostasis, which requires interrelated dynamics to maintain stability

   
   
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   3. Systemic theory brought a paradigm shift in our thinking, from the focus on the individual to interactions, patterns, connections, relationships and mutual influences between people. While non-systemic theories are based on a linear model of causality (A causes B), in a cybernetic model, causation is circular with mutual influence (A influences B, and B influences A through feedback loops). This is why the therapist intervenes at the relational system, rather than an individual patient

   
   
4. 
   

   4. Though the patterns may have been established over time, the therapist tends to focus on the ongoing interactions, that is, in the here and now. This was in part a reaction against the dominant psychoanalytic model of that time, drawing attention to current relationship patterns rather than analysing causes

First and Second Order Change

According to systemic family therapy there are two levels of change possible.

First order change occurs within the existing rules and structures and does not alter the operating system of the family. For example, when adolescent siblings fight the parents may use more or less punishment to control the fighting. The family’s rule is that that power is used to control their children and therefore the children use physical power to control each other. The punishment may reduce the problematic behaviour (fight) by first order change, but underlying rule (one must obey or submit to those in power) remains unchanged.

Second order change involves fundamental changes in the rules and norms of the family. If the fight is reframed, with a positive connotation, such that siblings are learning to practice autonomy as developing adults, the meaning of the fighting is transformed, and the ways to respond to it will be different.

Early Models of Systemic Therapy: First Order Cybernetics (1950s to mid 1970s)

In first order cybernetics, the assumption is that the therapist could stand outside the family system as an independent, objective observer. The therapist believes they have the expertise and power to make judgements about what is normal and healthy and intervene to make changes.

The Mental Research Institute (MRI) in Palo Alto opened in 1959 and became a leading organisation in the development of family therapy. Gregory Bateson, and his colleagues Don Jackson, Jay Healy, John Wakeland and William Fry, developed a model of Brief Family Therapy. In this model (MRI Brief Therapy), the problem was defined in clear, concrete terms and all previous attempted solutions were investigated. The therapist defined the desired changes in clear concrete terms and formulated and implemented a strategy for change. The MRI influenced the development of two schools of therapy, Structural Family Therapy and Strategic Family Therapy [9].

Virginia Satir, also working at the MRI, later developed Conjoint Family Therapy, which was firmly based on the family’s innate capacity for growth. Communication skills and expression of emotions were important in her model, which was a forerunner of a ‘strength-based approach’ to family therapy, focussing on strengths and resources in the family, rather than their problems, pathologies and deficits [10].

Structural Family Therapy was developed by Salvatore Minuchin, an Argentinian child psychiatrist who also trained in psychoanalysis, worked closely with Jay Haley and introduced the use of a one-way mirror by which therapists could observe therapy sessions with families. The basic premise in this model is that a well-functioning family has an organisational structure with clear hierarchies between generations. An effective parental hierarchy refers to the parent’s ability to set boundaries and limits while maintaining emotional closeness. Within the family structure are subsystems such as spousal, parental and sibling alliances. The boundaries of a subsystem are the rules defining who participates in a transaction and how. Coalitions, alignments and alliances between members are identified as contributing to the overall functioning and communication patterns within the family. Effective family boundaries are like the membrane of the cell: strong, but also remaining permeable. Healthy families are able to maintain an optimal balance between connectedness and differentiation, whereas less healthy family functioning is prone to either disengagement or enmeshment. In enmeshed families, boundaries are weak with low levels of individual differentiation and autonomy. In disengaged families, the boundaries are rigid and impermeable with low levels of nurturance or support to other members [11, 12].

In structural therapy, the therapist is active, like a stage director, setting up scenarios for enactments, and directing family members to interact in novel ways, to strengthen healthy and supportive structures within the family. An emphasis is placed upon ‘Joining’, the process by which therapists establish a working alliance with the family system. This is necessary before disrupting the pathological structures in treatment. Crisis induction forces the family to face a conflict that is typically avoided. In unbalancing, the therapist may deliberately create turbulence in the system by siding with one family member or ignoring a dominant member. These techniques as well as restructuring interventions challenge the rigid family hierarchy. Family sculpting is another way to enact the family dilemma.

Strategic Family Therapy was developed by Jay Haley and Chloe Madanes in the 1970s [13, 14]. The focus is on resolving presenting problems by disrupting sequences of behaviours and interactions which may maintain the difficulty and introducing alternatives to emerge. Gaining insight or understanding past influences are not emphasised in this model. Haley was influenced by Milton Erikson, a hypnotherapist who solved family problems through creative suggestions and paradoxes.

In strategic therapy, the first task of the therapist is to define a presenting problem in such a way that it can be solved. Again, the onus is on the therapist in his or her role as an expert to plan a strategy for solving the client’s problems. Strategic Interventions includes directives, paradoxical injunctions, and symptom prescription etc. An example of a directive from Haley, quoted by Madanes – ‘a father who is siding with his small daughter may be required to wash the sheets when daughter wets the bed. This task will tend to disengage daughter and father or cure the bed wetting’ [14]. Directives could be paradoxical, prescribing no change, which paradoxically triggers change.

Related posts:

Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations Chapter 10 – Cognitive Analytic Therapy (CAT): Chapter 11 – Group Analytic Psychotherapy and the Group Analytic Model: A Clinician’s Guide Chapter 16 – Complex Post-traumatic Stress Disorder Chapter 20 – Forensic Psychotherapy Chapter 25 – Therapeutic Communities

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