Family therapy in the adult psychiatric setting
Sidney Bloch
Edwin Harari
The term ‘family therapy’ covers a range of approaches. At one extreme, it is a method which seeks to help an individual patient. At the other extreme, the focus is on the relationships between people; according to this view psychopathology reflects recurring, problematic interactive patterns among family members. Midway between the two positions is one that views the family as acting potentially either as a resource or a liability for an identified patient. In this chapter, we cover the spectrum but confine ourselves to the adult psychiatric setting.
A historical and theoretical context
The family has long been recognized as a core aspect of social organization. The folklore of all cultures emphasize the family’s role to mould the character of its members. In the past 150 years academic disciplines, such as anthropology and sociology, have studied the various forms of family structure found in different cultures, and at different times. Since the 1960s, psychiatry has also developed a clinical and research interest in the family beyond that of genetics.
Scattered through Freud’s writings are interesting comments about marital and family relationships and their possible roles in
both individual normal and abnormal development.(1) His description of unconscious processes like introjection, projection, and identification illuminate how individual experiences may be transmitted across generations. In 1921, J.C. Flugel published the first comprehensive psychoanalytic account of family relationships.(2) Influenced by Anna Freud, Melanie Klein, and Donald Winnicott, the child guidance movement in Britain, mainly consisting of social workers, devised a model of one therapist working with the disturbed child and another with the mother. The two clinicians then collaborated in order to appreciate how the mother’s anxieties distorted her perception and handling of her child, leading to developmental difficulties.
both individual normal and abnormal development.(1) His description of unconscious processes like introjection, projection, and identification illuminate how individual experiences may be transmitted across generations. In 1921, J.C. Flugel published the first comprehensive psychoanalytic account of family relationships.(2) Influenced by Anna Freud, Melanie Klein, and Donald Winnicott, the child guidance movement in Britain, mainly consisting of social workers, devised a model of one therapist working with the disturbed child and another with the mother. The two clinicians then collaborated in order to appreciate how the mother’s anxieties distorted her perception and handling of her child, leading to developmental difficulties.
Proliferation of theoretical schools
Psychoanalytic and related approaches
Things took a different turn in the United States where Nathan Ackerman(3) began in the 1950s to treat families with a disturbed child, using psychodynamic principles. An interest in working with two or more generations arose concurrently with ‘transgenerational’-oriented family analysts using object-relations concepts. Thus, Murray Bowen(4) noted that the capacity of psychotic children to differentiate from their families, while still retaining a sense of age-appropriate belonging, was impaired by the effects of unresolved losses and other trauma in parental and grandparental generations. He also devised the genogram, a schematic depiction of family structure, with a notation for notable events; this remains a standard part of family assessment (see below).
Boszormenyi-Nagy and Spark(5) similarly addressed the transgenerational theme, describing how relationships were organized around a ledger of entitlements and obligations, which conferred on each family member a sense of justice or injustice about their situation. This, in turn, reflected childhood experiences of neglect or sacrifices made on another relative’s behalf for which redress was sought in adult life.
Systems-oriented (see later)
Bowen(4) also introduced the principles of ‘systems theory’ into family therapy. A system is defined as a set of interrelated elements that function as a unity within a particular environment and where the whole is larger than the sum of the parts. ‘General systems theory’, propounded in the 1940s by a German biologist,(6) contains among its key concepts the place of hierarchy and the emergence of new features in the system as it transforms itself, necessarily, from one level of organization to another. A family is an example of a partially open system that interacts with both its biological and socio-cultural environments and changes over time to accommodate developments such as the advent of a first child or the death of a grandparent.
Working with delinquent youth, Salvador Minuchin recognized the relevance of systems thinking. The youngsters often came from poor, emotionally deprived families, headed by a demoralized single parent (usually the mother) who alternated between excessive discipline and helpless delegation of responsibilities to a child or to her own critical mother. Since these families were beyond the reach of conventional ‘talking’ therapies, Minuchin applied actionoriented techniques which enabled him to ‘join’ the family and to re-establish an adaptive hierarchy and effective boundaries between subsystems (marital, parent-child, siblings).
Later, treating ‘psychosomatic families’ where the problem was a child or adolescent suffering from anorexia nervosa, unstable diabetes or asthma, Minuchin and his colleagues noted that these families, while intact and articulate, were often enmeshed. Members avoided challenging the apparent sense of family unity. Typically, marital conflict was detoured through the symptomatic child, resulting in maladaptive coalitions between parent and child (sometimes between grandparent and child) and the involvement of third parties (e.g. helping agencies) in family life; loss of hierarchy and boundaries ensued. Because words were used to avoid change in these well-educated families, non-verbal strategies were devised to face unspoken fears of conflict and change.(7)
Jay Haley’s ‘strategic therapy’(8) combined features of Minuchin’s model with ideas of Milton Erickson whose techniques had skilfully exploited the notion that a covert message lurks behind explicit communication, which defines the power relationship between family members. Related theoretical developments took place in Palo Alto, California in the 1950s, where a group of clinicians, together with the anthropologist Gregory Bateson,(9) observed that implicit in communication were tacit, non-verbal ‘meta-communications’ which defined the ties between participants. A contradictory quality between these two levels of communication —in which messages carried persuasive, moral, or coercive force for the recipient—formed part of what they called a ‘doublebind’; this form of entrapment was proposed, albeit erroneously, as a possible basis for the formal thought disorder found in schizophrenia.(10, 11)
(a) Systems-oriented models: further developments
All the above system-oriented views assume that family functioning can be objectively studied. However, therapists are not valuefree and may actively orchestrate changes in accordance with their preferred theoretical model; neglected in these circumstances are therapists’ biases and their influence.
This tendency probably reflected the determination of family therapists to distance themselves from psychoanalytical theory; but it also led them to neglect the family’s past history and changes through the lifecycle, including the relevance of traumatic events.
In response to this criticism there was a shift away from a problem-focused approach, which had typified most communicationbased views of psychopathology. The so-called Milan school(12) (see course of therapy below), whose founders were psychoanalysts, launched profound conceptual changes in how to approach the family, particularly in interviewing them. Another innovation was the participation of observers behind a one-way screen whose task was to offer hypotheses about the family-plus-therapist system to the protagonists.
A Norwegian group(13) took the idea one step further by developing the ‘reflecting team dialogue’. Here, following a session, the family could observe the therapeutic team discussing their problems and possible causes, and what factors might have prompted them to seek certain remedies—especially those they had persevered with despite the clear lack of effectiveness.
(b) Post-modern developments
Family therapists also began to ask whether families might be hampered from trying out new ways to solve their difficulties because of the ways they themselves had interpreted their past experiences or unwittingly absorbed the explanatory narratives of external ‘experts’ or society at large.
This led to a shift from considering the family as a system defined by its organizational structure to a linguistic-based one. According to this view the narrative a family relates about themselves is a means to integrate in specific ways their past experience and its significance. Other ‘stories’ are excluded from consideration. For instance, when a family with an ill member talk to health professionals, the conversations inevitably revolve around problems (a problem-saturated description). The family ignore times when problems were absent or minimal, or when they were confined to manageable proportions. A different story might be told if they were to examine the factors that could have led, or still lead, to better outcomes than those currently deemed pathological.
(c) Criticism of systems approaches
Many criticisms have been levelled at systems-based approaches, these include:
disregard of the subjective experiences of family members
neglect of the family’s history
inattention to unconscious motives in interpersonal behaviour
not addressing the issue of unequal power in a family, particularly violence against women and child abuse, and
ignoring various forms of injustice based on societal attitudes regarding gender, ethnicity, and class.
This critique has led to integrating systems-oriented and psychoanalytic concepts, particularly those derived from object-relations theory.(17,18,19,20) Specific disorders such as schizophrenia(21) and anorexia nervosa(22) have been targeted. Another noteworthy variant of integration is Byng-Hall’s(23) synthesis of attachment theory, systems-thinking, and a narrative approach.
Another criticism of systems-oriented approaches is minimizing the impact of material reality, such as physical handicap, or biological factors, in the causation of mental illness, as well as sociopolitical phenomena like unemployment, racism, and poverty. These are obviously not merely the result of social constructions or linguistic games and the distress they may inflict on people are potentially considerable.
The ‘psycho-educational’ approach and ‘family crisis intervention’ have arisen in the context of the burden that severe mental illness, particularly schizophrenia, places on the family and the potential for members to influence dramatically the course of the condition. This has led to a series of family interventions:
educating the family about the nature, cause, course, and treatment of schizophrenia
providing the family with opportunities to discuss their difficulties in caring for the patient, and to devise pertinent strategies
clarifying the role of conflict, not only about the illness but also about other relational issues
regularly evaluating the impact of the illness on the family, both individually and collectively
helping to resolve other conflicts possibly aggravated by the demands of caring for a enduringly ill person.
This type of work may be done with a single family or with several families meeting together, known as Multiple-Family Group Treatment (MFGT). The latter has emerged as a powerful adjunct to conventional individual-based treatment of schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder, somatization disorder, and an array of chronic medical conditions. Good results have been achieved in reducing the relapse rate, duration, and frequency of hospitalization and in boosting compliance with medication.(24) Family crisis intervention, initially devised for families with a schizophrenic relative but since applied to other clinical states, operates on the premise that deterioration or a request by the family to hospitalize a member may reflect change in a previously stable pattern of family functioning. Convening an emergency meeting with the patient, spouse, and other key family members may help to avoid admission. Social and institutional forces outside the family often contribute to a crisis, and may precipitate a psychotic episode in a vulnerable member. The ‘open dialogue’ model of family crisis interviewing, developed in Finland, fosters discussion about such forces, using concepts and techniques derived from, inter alia, the Milan school, narrative approaches, and psychodynamic thinking; this integrated perspective has much potential.(25)
Indications
A measure of controversy has dogged the issue of what constitutes the indications for family therapy. Pioneering practitioners claimed, somewhat overzealously, that their methods were suited to most conditions. A more balanced view since the mid-1990s encompasses a consensus that considering the systemic context is advantageous in assessing and treating any psychiatric problem. However, it does not follow that family therapy is the treatment of choice (or even indicated).
Family therapy, it should be stressed, does not constitute a unitary approach, with one principal purpose. The diversity of theoretical models we have alluded to above, with their corresponding techniques, should make this obvious. Regrettably, attempts to link indications to specific models have contributed little to the field.
It has also become clear that DSM or ICD diagnoses do not serve well as a basis for determining indications for family interventions. DSM has a minuscule section, the V diagnoses, covering ‘relational problems’; these are limited in scope and not elaborated upon.(26) We are only informed that the problem in relating can involve a couple, a parent, and child, siblings, or ‘not otherwise specified’. ICD neglects this relational area entirely.
In mapping out indications, we need to avoid blurring family assessment and family therapy. A patient’s family may be recruited in order to gain more knowledge about diagnosis and treatment. This does not necessarily lead to family therapy. Indeed, it may point to marital therapy or to long-term supportive therapy. Thus, we need to distinguish carefully between an assessment family interview and family therapy per se.
A typology of family psychopathology, which might allow us to differentiate one pattern of dysfunction from another and so map out corresponding interventions, remains elusive. Empirical evidence is inconclusive and clinical consensus lacking. An inherent difficulty is in selecting dimensions of family functioning central to creating a typology.(27) Communication, cohesiveness, adaptability,
boundaries between family members and subgroups, and level of conflict are a few of the contenders offered (see our own classification below).
boundaries between family members and subgroups, and level of conflict are a few of the contenders offered (see our own classification below).
There are no clear correlates between conventional diagnoses and family type. Efforts to establish links, such as an anorexia nervosa family(28) or a psychosomatic family(29) have not been fruitful. Similarly, investigations into the family and schizophrenia have yielded no durable results.(4,10) Clinicians and researchers have reluctantly accepted that models of effective family-based treatment for mental illness may not necessarily follow an understanding of the apparent causes of a condition in terms of observed disturbances in family relating. This complex matter is helpfully reviewed by Eisler regarding studies of the treatment of anorexia nervosa, but has implications for the entire field.(30)
What follows is our attempt to distil clinical and theoretical contributions.(31) Given the considerable overlap in clinical practice, categories are not mutually exclusive; and a family may require family therapy based on more than one indication. We should stress that family dysfunction is obvious in certain clinical situations and covert in others, often being concealed by a specific member’s clinical presentation. Six categories emerge:
1 The problem manifests in explicit family terms and the therapist readily notes the family’s dysfunction. For example, a marital conflict dominates, with repercussions for the children; or tension between parents and an adolescent child dislocates family life with everyone ensnared in conflict. In these situations the family is the target of intervention by dint of its clear dysfunctional pattern, and family therapy undoubtedly is the treatment of choice.
2 The family has experienced a disruptive life event which has led to its dysfunction. These events are either predictable or accidental and include, for instance, suicidal death, financial embarrassment, diagnosis of a serious physical illness, and the unexpected departure of a child from home. Any family stability that prevailed previously has been disturbed; the ensuing disequilibrium becomes associated with family dysfunction and/or the development of symptoms in one or more members. Family efforts to rectify the situation may inadvertently aggravate it.
3 Continuing, demanding circumstances in a family are of such a magnitude as to lead to ineffective adjustment. The family’s resources may be stretched to the hilt; external sources of support may be scanty or unavailable. Typical situations are chronic physical illness, persistent or recurrent psychiatric illness, and the presence of a frail elderly member.
4 An identified patient may have become symptomatic in the context of a dysfunctional family; symptoms are in fact an expression of that dysfunction. Depression in a mother, an eating problem in a daughter, alcohol misuse in a father, through family assessment, are adjudged to reflect underlying family difficulties.
5 A family member is diagnosed with a conventional condition such as schizophrenia, agoraphobia, obsessive-compulsive disorder, or depression; the complications are the adverse reverberations within the family stemming from that diagnosis. For example, the son with schizophrenia taxes his parents in ways that exceed their ‘problem-solving’ capacity; an agoraphobic woman insists on the constant company of her husband in activities of daily living; a recurrently depressed mother comes to rely on the support of her eldest daughter. In these circumstances, members begin to respond maladaptively to the diagnosed relative, which paves the way for a deterioration of her condition, manifest as an enduring or relapsing course.
6 Thoroughly disorganized families, buffeted by many problems, are viewed as the principal target of help. This is apposite, even though, for instance, one member abuses drugs, another is prone to violence, and a third manifests antisocial behaviour. Regarding the family as the core dysfunctional unit is the rationale rather than a focus on each member’s individual problems.
To reiterate, family therapy may not be the only treatment indicated. Thus, in helping a disturbed family struggling to deal with a schizophrenic member, supportive therapy and medication for the patient are usually as pertinent as any family treatment. Similarly, an indication for family therapy does not negate the possible use of another psychological approach for one or more family members. For instance, an adolescent striving to separate and individuate may benefit from individual therapy following family treatment (or in parallel with it), while his parents may require a separate programme to focus on their sexual relationship.
Contraindications
These are self-evident and therefore mentioned only briefly.
1 The family is unavailable because of geographical dispersal or death.
2 Shared motivation for change is lacking. One or more members may wish to participate, but their chances of benefiting from a family approach are likely to be less than if committing themselves to individual therapy. We need to distinguish here between poor motivation and ambivalence; in the latter, the assessor teases out factors that underlie it and may encourage the family to engage.
3 The level of family disturbance is so severe or long-standing, or both, that a family approach seems futile, according to the best possible clinical judgement. For example, a family that has fought bitterly and incessantly for years is unlikely to engage in the constructive purpose of exploring their patterns of functioning.
4 Family equilibrium is so precarious that the inevitable turbulence(32) arising from family therapy is likely to lead to decompensation of one or more members; for example, a sexually abused adult may do better in individual therapy than by confronting the abusing relative.
5 The patient is too incapacitated to withstand the demands of family therapy. Someone in the midst of a psychotic episode or buffeted by severe melancholia is too affected by the illness to engage in family work.
6 An identified patient acknowledges family factors in the evolution of his problem, but seeks the privacy of individual therapy to explore it, at least initially. For example, a university student struggling to achieve a coherent sense of identity may benefit more from her individual pursuit of self-understanding. Such an approach does not negate an attempt to understand the contribution of family factors to the problem.
Assessment
Family assessment, an extension of individual psychiatric assessment, adds a broader context to the formulation. The range and pace of the enquiry depends on the specifics of the case. Its phases are history from the patient, a provisional formulation concerning the relevance of the family, an interview with one or more members, and a revised formulation. In some cases, it is clear from the outset that the problem resides in the family group, thus rendering the phases below superfluous.
History from the patient
The most effective way to obtain a family history is by constructing a family tree. Apart from showing the structure, it allows relevant information about noteworthy life events and a range of family features to be added. Scrutiny of the tree also provides a source of issues warranting exploration and, eventually, the potential for formulating hypotheses.
Personal details such as age, date of birth and death, occupation, education, and illness are recorded for each member, as well as critical family events (for example, migration, crucial relationship changes, notable losses, and achievements), and the quality of relationships. For an excellent discussion of the family tree—its construction, interpretation, and clinical uses—see McGoldrick and Gerson.(33) (See Fig 6.3.8.1 for genogram conventions.)
Useful principles are to work from the presenting clinical problem to the broader context, from the current situation to its historical origins and evolution, from ‘facts’ to inferences, and from non-threatening to more sensitive themes.
Questions are best preceded by a statement such as: ‘In order to understand your problems better I need to know something of your background and your current situation’. This can be enriched by questions that allude to interactive patterns: ‘Who knows about the problem? How does each of them see it? Has anyone else in the family faced similar problems? Who have you found most helpful and least helpful so far? What do they think needs to be done’. Attitudes of family members can be thus explored and light shed on the clinical picture.
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