Since the publication of the last volume of this textbook, family therapy has continued to expand its scientific base and theoretical evolution. Evidence-based programs primarily delivered as home-based, family-centered interventions in the community have continued to produce impressive results with adolescents with conduct disorders and substance abuse. Family interventions also have been applied systematically in controlled studies to a very broad range of clinical disorders of children and adolescents.

The fundamental theoretical concepts and technical interventions developed by pioneers in family systems and psychodynamic therapy have been adopted by the contemporary generation of family therapists who apply them in a multidimensional and ecological manner, incorporating the characteristics of the children, their peer group, community, and broader culture. This broad framework has allowed the incorporation of other treatment modalities, such as cognitive behavior therapy (CBT) and pharmacotherapy, which has significantly enhanced treatment effectiveness. A more flexible approach to involving parents has enhanced engagement in treatment, retention, and treatment outcome. Partly in response to these developments, NIMH has encouraged the use of family interventions in investigative projects; more than half of NIMH-funded intervention proposals and programs include a family component (1).

Family theory focuses on human behavior and psychiatric disturbances in the context of interpersonal relationships (2,3,4). This theory forms the basis of family therapy, which is an umbrella term for a number of clinical practices that treat psychopathology within the context of family systems rather than individuals. Interventions are designed to effect change in family relationships rather than in an individual (2,5). This approach is based on observations that symptomatic behavior appears in individuals involved in certain dysfunctional processes within their families or with other significant persons. Conversely, positive family interactions such as effective parenting practices, emotionally nurturing family environments and secure attachment relationships are associated with normative child development, healthy functioning and serve as protective factors against emotional disorders (6).

Family theory considers the family as an interpersonal system with cybernetic qualities. The relationships among the components of the system are nonlinear (or circular); the interactions are cyclical rather than causative. Complex interlocking feedback mechanisms and patterns of interaction among the members of the system repeat themselves sequentially. Any given symptom can be viewed simply as a behavior functioning as a homeostatic mechanism that regulates family interactions (7).

The family system is nonsummative and includes the assets and dysfunctions of the individuals as well as their interactions (8). A person’s problems cannot be evaluated or treated apart from the context in which they occur and the functions that they serve. It is assumed, therefore, that an individual cannot be expected to change unless the family system changes (8). Treatment addresses the behavioral dysfunctions as a manifestation of disturbances within the entire family relational system; the role of the total family in aiding or in sabotaging treatment is the focus even when a distinct diagnosable psychiatric illness is present in one of the family members.

The goals of family therapy as a psychotherapeutic approach are as follows (3)

The term family therapy has been expanded to include family intervention, a broader array of procedures. It subsumes a large number of clinical practices based on a variety of theoretical concepts with explicit focus on altering the interactions among family members and subsystems with the goal of improving the functioning of the family as a unit, its subsystems and members. Treatment of disturbed individuals as well as dysfunctional relationships can be achieved through family interventions (3,4). Improved functioning in parental and parent/child subsystems is a fundamental goal in treatment of children and adolescents.

Family therapy and conjointed treatment of families emerged in the late 1940s and early 1950s. The towering figures in the field were Nathan Ackerman, Gregory Bateson, Murray Bowen, Bell, Theodore Lidz, Don Jackson, Jay Heley and many others. Family therapy with a focus on children and adolescents was introduced by Carl Whitaker, Salvadore Minuchin and more recently by David and Jill Scharff, Joan Zilbach and others. A detailed description of the history can be found in recent literature (9,10).

In late 1960s, Minuchin in collaboration with Montalvo and Haley established the Structural School of Family Therapy. The structural approach reached its height in theoretical development by defining the term psychosomatic families— the families of patients with anorexia nervosa and other psychosomatic disorders (11). The structural approach has been applied extensively to families of children with behavior disorders (12).

An underappreciated approach to family therapy with adolescents and children was attempted by the Multiple Impact Therapy group (MIT) in Galveston, Texas (13). The novel intervention by this group included 2 days of family therapy by a number of professionals who alternated their work with different family members during the therapeutic encounter. They classified the families according to the disorders of the adolescents and children, mostly oppositional/defiant and conduct disorders.

An apparent and clear indication for family therapy is open and stressful conflicts among family members, with or without symptomatic behaviors in one or more members. Family therapy also can be applicable when there are covert problems within the family, which can give rise to dysfunctional behavior in one or more family members, or when other family members covertly support and perpetuate the disorder. Recognizing covert family interactional problems coexisting with overt dysfunctions in one or more family members is the specific contribution of the field of family therapy. Recently, family interventions have been used extensively with externalizing adolescent disorders and substance abuse.

Contraindications to family therapy are relative rather than absolute. They include discussing long dormant, charged, or explosive family issues with the whole family before the family commits seriously to treatment. Another relative contraindication is discussing stressful situations with the family when one or more members are severely destabilized and require hospitalization. Insufficient expertise in family therapy relative to a high level of resistance and defensiveness in the family can result in a counterproductive treatment course. Lack of knowledge of child development and psychopathology can render family intervention with children and adolescents equally unproductive and result in missed therapeutic opportunities.

The diversity of models of family therapy raises questions about the common ground among family therapies. The pioneers in family therapy focused on different dimensions in the family system, and to some degree, these different focuses reflected unrecognized differences among patient populations treated by the early family therapists. Although family therapists adopted divergent paths, they ignored the likely conclusion that different approaches to family therapy are closely linked to family characteristics commonly observed in different disorders.

Different models of family therapy are applicable to various patient populations. The intergenerational family therapy models are particularly applicable to families whose members have longstanding disorders and have not negotiated adequate separation and differentiation between the generations (14,15). Structural and strategic family therapies are particularly applicable to families encountering a crisis situation in which there has been adequate separation from previous generations and a reasonably satisfactory precrisis adjustment in the nuclear family. Behavior family therapy is particularly applicable to marital problems and children with chronic conduct disorders. Psychodynamic and experiential family therapies are helpful to family members with narcissistic vulnerability and a broad range of personality and neurotic disorders who have maintained a relatively adequate level of functioning but find little enjoyment in their lives. An emerging array of family-based interventions attempt to reverse the disintegrative processes in chronically and seriously disordered families effected by abuse, neglect, and placement of the children outside of the family.

Each model of family therapy includes different theoretical concepts and techniques. Some models of family therapy can be grouped based on their similarities. The major models of family therapy, their core concepts, goals, and approaches and techniques, are summarized in Table 6.2.6.1.

Solution-focused therapy concentrates on the “exceptional solution” repertoire already practiced by the patients to deemphasize their problem-saturated outlook and enlarge the application of such solutions. The therapeutic effectiveness is enhanced by shifting the focus to the “solution” rather than the “problems” (10,17).

Psychodynamic family therapy emphasizes individual maturation, personality development, early childhood experiences, and resolution of symptoms and conflicts in the context of the family system. Common theoretical concepts of psychodynamic family therapy include projective identification, shared unconscious conflicts and defenses, intrafamilial transference reactions, dyadic and triadic family transferences in treatment, and a host of object relations psychoanalytic concepts, such as holding environment and empathy.

Behavior family therapy applies the principles of positive and negative reinforcement to the family unit with the goal of enhancing reciprocity and minimizing coercive family processes. Coercive family processes generally are in the form of punishment, avoidance, and power play. Enhancing communication and problemsolving skills in the family is emphasized and punishment is discouraged.

Contemporary behavior family therapy is based on social learning theory and has been applied in the form of parent management training (PMT). The parents and children are taught environmental contingencies (positive and negative reinforcement, reward and punishment) which shape behavior. Strong attention is paid to enhancing prosocial behavior.

Behavior family therapy can be combined with communication and problemsolving training.

Psychoeducational family intervention based on stress–diathesis theory attempts to enhance family adaptation primarily through informing the family and patient about the nature of psychopathology in psychiatric disorders. The family and patient also receive detailed information about the treatment process and outcome. Psychoeducational intervention has been applied extensively in treating major mental illnesses such as schizophrenia, depression, alcoholism, and anxiety disorders. It consists of a series of in-depth and expert instructional sessions on the phenomenology, etiology, and diagnosis of the disorders. Clinical research findings are explained and made user friendly for the family. Information is also provided about social institutions and systems involved in the care of the patient. Psychoeducational family therapy can be easily combined with other treatment modalities, particularly pharmacotherapy and crisis intervention. The psychodynamic and exploratory psychotherapies are postponed to the later phases of treatment, when the patient and the family are stabilized.

Psychoeducational approaches make extensive use of empirical findings on expressed emotion (EE), communication deviance, affective styles, and problemsolving. This reduces the stressful family processes, recurrence in illness and rehospitalization.

The application of psychoeducational model to childhood depression and suicidality has been particularly productive. The model has been applied preventively to a range of stressful and potentially pathogenic situations for the children such as pediatric cancer, death, and dying. A model for prevention of depression in children of depressed parents has been empirically tested by Beardslee et al. (18) in the past decade with positive outcome.

The term family life cycle proposes that the family moves through a series of developmental stages. Carter and McGoldrick defined critical emotional issues for the family at different stages of the life cycle (19). Haley (8) applied the family life cycle concept to understanding the clinical problems of families by relating their dysfunctions to the difficulties they have in moving from one developmental stage to another.

Marriage is considered the first stage of family life cycle (20). The expectable seven stages of the family life cycle are 1) beginning family, 2) childbearing family, 3) family with school age children, 4) family with teenagers, 5) family as a launching center, 6) family in its middle years, and 7) aging family. Combrinck-Graham (21) proposed the family life spiral, with overlapping development issues for different generations.

The conceptional and technical differences between the fields of child psychiatry and family therapy can be summarized in the following way. Child psychiatrists have accused systemic family therapists of lack of appreciation for the individual child’s unique developmental characteristics and intrapsychic life (22,23). According to child psychiatrists, family therapists were oblivious to biological vulnerabilities and pharmacotherapy. Conversely, family therapists have accused child psychiatrists of lacking understanding of the interpersonal dimensions of the child’s life, the multiple sources of stress in contemporary family life, and preoccupation with minute developmental deviations and past events at the expense of present-life realities.

In the 1980s, the two camps approached reconciliation. Recognition of family therapy’s limitations with certain populations forced many family therapists to reach “beyond family therapy” and address peer-group, psychological (intrapsychic and cognitive), and social dimensions of behavior disorders. Teaching family therapy has been a requirement in child and adolescent, as well as general, psychiatric residency programs for the past 20 years. The integrative approach in treating major mental illnesses has resulted in the consolidation of a true field of family psychiatry (10,24). Psychodynamic and object relations family therapies have demonstrated the many advantages of recognizing the interrelationships between interpersonal and intrapsychic processes (25,26,27).

We briefly summarize the application of family therapy to multiple disorders of children and adolescents and refer the reader to the references listed for more information.

All schools of family therapy are founded on theoretical concepts that are specifically applicable to family therapy with children and adolescents. In enmeshed families, there is not sufficient distance and objectivity among family members to allow differentiation of the children through the separation and individuation processes. The children have significant difficulties in school and social relationships, further curtailing their maturity. Overinvolvement between a child and a parent, projective family mechanisms, and triangulation as described by Bowen are major impediments to differentiation and maturity, which can transfer across generations.

Projective identification describes the unconscious processes of projection of unresolved parental conflicts onto a child, who assumes an identity based on a historically assigned role. Assumption of this role interferes with the child’s appropriate identity formation. Traumatic events such as child neglect and physical or sexual abuse in the early history of the family can result in the repetition of such traumatic situations in subsequent generations. “Parentification,” another impediment to the child’s development, assigns a parental role to a child and deprives him or her of age-appropriate experiences.

Although many schools of family therapy recognize the significance of the separation-individuation process for adolescent family members, few of them describe the intricate network of developmental failures within the family and the adolescent that undermine the separation-individuation process. Stierlin (28) proposed that binding, delegating, and expulsion are three ways that families negotiate a pathological separation to overcome the fear of prolonged fusion. In the binding mode, the excessive binding of the family to the adolescent can force the growing adolescent into psychotic or suicidal behavior to free himself or herself from the family unit. In the intricate delegating mode, the family allows the adolescent to depart from the family unit “on a long leash” to return periodically to share the tales of his or her exploits in order to compensate for the restricted life of the parents. In the expulsion mode, the adolescent is rejected by and extruded from the family to free him or her from the family unit.