Family-Based Therapy

Family-Based Therapy

Family therapy is a broad “umbrella concept” that encompasses a great many specific clinical interventions that share certain characteristics but that differ significantly in their underlying theoretical principles and orientation, their techniques and implementation, and the specific problems and disorders they aim to ameliorate. Within this broad category can be found psychodynamic approaches, cognitive and behavioral approaches, strategic approaches, and others. Since its early development, around the middle of the 20th century, family therapy has evolved considerably. The strict divide between the field of family therapy and the fields of psychiatry and psychology has been gradually (and partially) bridged, and family therapy has gained a place of prominence and respect in the overall landscape of mental health services. This chapter reviews key parts of the history of family therapy and discusses several of the theoretical models and applied implementations, as they relate to the treatment of children and adolescents.


The roots of family therapy are often traced to the decade following World War II, and to the challenges and problems caused by the large-scale reunification of families who sought mental health counseling to address them. Roles that had been traditionally filled by the broader community, including extended family, schools, and religious organizations, became the purview of clinical providers. These providers began to turn their attention increasingly to the family system as an integrated unit, where previously the focus had been almost exclusively on the individual and the problems of the “patient.”

An important early influence on the development of family therapy as a theoretical field was the work of Gregory Bateson (Bateson et al., 1956). Bateson, a linguist and anthropologist, applied concepts from communications and cybernetics to human communication, including within family systems. Most notably, in collaboration with other researchers, Bateson developed the double-bind theory as a proposal for understanding the etiology and symptoms of schizophrenia. The double-bind refers to situations in which a person receives contradictory messages or injunctions through different forms of communication. For example, a parent whose words convey love for a child but whose actions express disdain or detachment. When the contradictory injunctions demand a response from the child, who is unable to satisfy both
and perceives a threat of punishment for not doing so, the double-bind can trigger anxiety, stress, and confusion. Ultimately, over repeated such instances the child may become suspicious of all communication and may respond to the confusing messages with equally disjointed communication of their own. This was suggested to be the onset of the schizophrenic illness. Although researchers today no longer attribute the etiology of schizophrenia to parental behaviors or specific forms of maladaptive parenting, the influence of the theory lies in its departure from individual models that emphasize only the inner psyche, in favor of an emphasis on relationships and interpersonal systems.

Another proposal for the etiology of schizophrenia that exerted an early influence on the field of family therapy was the work of Frieda Fromm-Reichmann on the so-called schizophrenogenic mother (Fromm-Reichmann, 1948). The theory posited that distant and aloof, but possessive and manipulative mothers, in combination with passive and ineffective fathers, cause children to feel inadequate and bewildered and ultimately to develop schizophrenia. Like the double-bind, the schizophrenogenic mother theory is no longer viewed as an empirically sound theory for the etiology of schizophrenia, but it remains important for its impact on family therapy and contribution to the shift toward a systemic family-based view of psychopathology.

Other early contributors to the field include Theodore Lidz who emphasized the importance of maladaptive fathering and disrupted marital relationships, Murray Bowen who emphasized multigenerational transmission of unhealthy relationships, Nathan Ackerman who published the first paper addressing treatment with an entire family in 1937 (Ackerman, 1937), John Bell who was among the first to regularly meet with families in a clinical setting, Carl Whitaker who began working with families during the 1940s and organized early family therapy conferences that included interviewing families behind a one-way mirror, and many others.

By the 1960s, family therapy had gained a respected place in the field of mental health, although it remained dominated, at least in practice, by social workers rather than psychologists or psychiatrists who continued to focus on the individual patient and on intrapsychic processes rather than interpersonal systems. A journal, Family Process, was established and remains highly influential to this day, although numerous other journals that emphasize family-based approaches have since come into existence. And despite the early focus on adults with mental illness (and in particular schizophrenia), applications of family therapy to the problems of children and adolescents also emerged.

The work of Salvador Minuchin is particularly influential in this regard. Minuchin developed structural family therapy, a theory-driven approach to family therapy grounded in empirical research and inspired by his work with youth in underprivileged communities (Minuchin & Nichols, 1998). Structural family therapy aims to map relationships between family members and to dislodge unhealthy patterns of intra-family transactions, allowing the emergence and stabilization of healthier and more adaptive patterns.

Although much of the work in the field of family therapy occurred in the United States, important centers also emerged in other locations. Notably, Mara Selvini-Palazzoli founded the Institute for Family Studies in Milan, a group that became highly influential in the field for a long time.

The 1980s are the decade many consider to be the heyday of family therapy. Journals dedicated to the field proliferated, national and international professional associations sprung up with many active members, the American Psychological Association established a division dedicated to family psychology, and professionals could become board certified in family therapy. This surge in focus on family therapy also led to certain criticisms, including that the field was placing excessive focus on pragmatic solutions, at the expense of deep and full understanding of the family system in which the problems are emerging, and that treatments were being advanced without enough empirical evidence to support their efficacy. In recent decades, family therapy has broadened its scope and has placed increased emphasis on establishing competency benchmarks for clinicians and on establishing evidence-based practices for the field.


Psychodynamic Family Therapy

Psychodynamic therapy originates with the work of Freud and places special emphasis on drives and processes that occur outside of conscious awareness. In psychodynamic therapy, the role of the analyst involves understanding these processes through (among other things) interpretation of transference and countertransference and of resistance on the part of the patient (see Chapter 5 for a brief overview of psychodynamic therapy). Ackerman published early research describing the entire family as a single psychosocial unit and was the first to apply the concepts of psychodynamic theory and practice to family therapy (Ackerman, 1958). His work with families emphasized the unconscious processes that occur between family members and he sought to tackle defensiveness in family members by encouraging open and frank discussion of any topic. However, Ackerman did not delineate a specific theoretical model underlying his work.

An example of a more clearly laid out theory of psychodynamic family therapy is the work of David Scharff and Jill Savege Scharff (a married couple) (Scharff, 1989). This work built on objects relations theory, a development of psychoanalysis that emphasizes the relationship between infant and caregiver as the foundation for adult identity and personality. In object relations family therapy, the therapist elicits unconscious material from dreams and fantasies to help patients gain insight into how past experiences are impacting their current relationships. Transference, rather than being viewed as something that happens exclusively between patient and therapist, is thus understood to occur between family members and between the family and the therapist and can be interpreted by the therapist to advance the therapeutic process. Observing the family and how family members interact with each other provides the therapist with information about each member’s object relations and can enable increased understanding, and ultimately a stabilization of the family system.

Other forms of psychodynamic therapy have also been translated to the family therapy domain, including Kohut’s self-psychology and, more recently, relational psychoanalysis.

Transgenerational Family Therapy

Transgenerational models of family therapy posit that current problems experienced by family members have their roots in the passed-on issues of previous generations. Essentially, when problems are not successfully resolved in one generation, they echo onward through future generations, sometimes growing in severity and leading to symptoms of psychopathology. Particularly notable in this context is the work of Murray Bowen (Bowen, 1966). Bowen emphasized the conflicting drives within families for both cohesive togetherness and for separation and autonomy. He posited this conflict as a central issue impacting all people. Bowen suggested that over-entanglement between children and parents, through the process of enmeshment, could lead to triangulation within families—involving everyone in the family and not only the mother-child dyad (Bowen, 1972). He articulated a theory comprising several key concepts relating to both the current family and to the transgenerational impact of previous generations.

Believing that all human beings must contend with anxiety, Bowen suggested that the transgenerational transmission of anxiety can lead the current family to an imbalanced resolution of the conflicting drives for togetherness and autonomy. This in turn causes enmeshment and triangulation, and even more anxiety. Bowen’s Family Systems Therapy aimed to “detriangulate” families and to increase family members’ individuation, thus reducing the level of anxiety experienced by the family members and by the family as a whole. Family systems therapy includes a set of strategies and techniques to foster communication and insight, including the use of genograms to chart family history over generations.

Of note, in the context of children and adolescents, Bowen’s approach centered on work with couples, even when the identified patient was a child. The belief that the marital relationship, influenced by each spouse’s generational history, is at the root of children’s difficulties led to this focus, which differs from most forms of family therapy that involve the entire family unit in the therapeutic process.

Structural Family Therapy

In Structural Family Therapy, the underlying structure and organization of the family system is carefully mapped out. This refers to the complex set of rules, norms, and demands that determine how family members interact with each other within the family system.

Salvador Minuchin, the developer of structural family therapy, proposed that this self-perpetuating structure and its degree of flexibility are critical to a family’s ability to contend with the changing challenges of life (Minuchin, 1974; Minuchin & Fishman, 1981; Minuchin & Nichols, 1998). A family that is open to change in its underlying structure will be better able to cope adaptively with transitions and novel demands. Conversely, a family that is rigidly clinging to a firmly fixed structure will struggle with periods of change and become less functional. Thus, the structural family therapist will help families by enabling changes in the structure of dysfunctional families, paving the way for more adaptive patterns to emerge.

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Jun 19, 2022 | Posted by in PSYCHOLOGY | Comments Off on Family-Based Therapy
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