Family therapy is a type of psychotherapy that involves all members of a nuclear family or stepfamily and, in some cases, members of the extended family (e.g., grandparents). A therapist or team of therapists conducts multiple sessions to help families deal with important issues that may interfere with the functioning of the family and the home environment.
The goal of family therapy is to help family members improve communication, solve family problems, understand and handle special family situations (for example, death, serious physical or mental illness, or child and adolescent issues), and create a better functioning home environment. For families with one member who has a serious physical or mental illness, family therapy can educate families about the illness and work out problems associated with care of the family member. For children and adolescents, family therapy most often is used when the child or adolescent has a personality, anxiety, or mood disorder that impairs their family and social functioning, and when a stepfamily is formed or begins having difficulties adjusting to the new family life. Families with members from a mixture of racial, cultural, and religious backgrounds, as well as families made up of same-sex couples who are raising children, may also benefit from family therapy.
Family therapy is generally conducted by a therapist or team of therapists who are trained and experienced in family and group therapy techniques. Therapists may be psychologists, psychiatrists, social workers, or counselors. Family therapy involves multiple therapy sessions, usually lasting at least one hour each, conducted at regular intervals (for example, once weekly) for several months. Typically, family therapy is initiated to address a specific problem, such as an adolescent with a psychological disorder or adjustment to a death in the family. However, frequently, therapy sessions reveal additional problems in the family, such as communication issues. In a therapy session, therapists seek to analyze the process of family interaction and communication as a whole and do not take sides with specific family members. Therapists who work as a team can model new behaviors for the family through their interactions with each other during a session.
Family therapy is based on family systems theory, in which the family is viewed as a living organism rather than just the sum of its individual members. Family therapy uses systems theory to evaluate family members in terms of their position or role within the system as a whole. Problems are treated by changing the way the system works rather than trying to fix a specific member. Family systems theory is based on several major concepts.
Concepts in family therapy
THE IDENTIFIED PATIENT The identified patient (IP) is the family member with the symptom that has brought the family into treatment. Children and adolescents are frequently the IP in family therapy. The concept of the IP is used by family therapists to keep the family from scapegoating the IP or using him or her as a way of avoiding problems in the rest of the system.
HOMEOSTASIS (BALANCE) Homeostasis means that the family system seeks to maintain its customary organization and functioning over time, and it tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change.
THE EXTENDED FAMILY FIELD The extended family field includes the immediate family and the network of grandparents and other relatives of the family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviors, and other issues. Children and adolescents often benefit from family therapy that includes the extended family.
DIFFERENTIATION Differentiation refers to the ability of each family member to maintain his or her own sense of self, while remaining emotionally connected to the family. One mark of a healthy family is its capacity to allow members to differentiate, while family members still feel that they are members in good standing of the family.
TRIANGULAR RELATIONSHIPS Family systems theory maintains that emotional relationships in families are usually triangular. Whenever two members in the family system have problems with each other, they will “triangle in” a third member as a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that maintains family homeostasis. Common family triangles include a child and his or her parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.
In the early 2000s, a new systems theory, multisystemic therapy (MST), has been applied to family therapy and is practiced most often in a home-based setting for families of children and adolescents with serious emotional disturbances. MST is frequently referred to as a “family-ecological systems approach” because it views the family’s ecology, consisting of the various systems with which the family and child interact (for example, home, school, and community). Several clinical studies have shown that MST has improved family relations, decreased adolescent psychiatric symptoms and substance use, increased school attendance, and decreased re-arrest rates for adolescents in trouble with the law. In addition, MST can reduce out-of-home placement of disturbed adolescents.
In some instances the family may have been referred to a specialist in family therapy by their pediatrician or other primary care provider. It is estimated that as many as 50 percent of office visits to pediatricians have to do with developmental problems in children that are affecting their families. Some family doctors use symptom checklists or psychological screeners to assess a family’s need for therapy. For children and adolescents with a diagnosed psychological disorder, family therapy may be added to individual therapy if family issues are identified as contributing factors during individual therapy.
Family therapists may be either psychiatrists, clinical psychologists, or other professionals certified by a specialty board in marriage and family therapy. They usually evaluate a family for treatment by scheduling a series of interviews with the members of the immediate family, including young children, and significant or symptomatic members of the extended family. This process allows the therapist(s) to find out how each member of the family sees the problem, as well as to form first impressions of the family’s functioning. Family therapists typically look for the level and types of emotions expressed, patterns of dominance and submission, the roles played by family members, communication styles, and the locations of emotional triangles. They also note whether these patterns are rigid or relatively flexible.
Preparation also usually includes drawing a genogram, which is a diagram that depicts significant persons and events in the family’s history. Genograms include annotations about the medical history and major personality traits of each member. Genograms help uncover intergenerational patterns of behavior, marriage choices, family alliances and conflicts, the existence of family secrets, and other information that sheds light on the family’s present situation.
Individual therapy for one or more family members may be recommended to avoid volatile interaction during a family therapy session. Some families are not considered suitable candidates for family therapy. They include:• families in which one, or both, of the parents is psychotic or has been diagnosed with antisocial or paranoid personality disorder• families whose cultural or religious values are opposed to, or suspicious of, psychotherapy• families with members who cannot participate in treatment sessions because of physical illness or similar limitations• families with members with very rigid personality structures (Here, members might be at risk for an emotional or psychological crisis.)• families whose members cannot or will not be able to meet regularly for treatment
The chief risk in family therapy is the possible unsettling of rigid personality defenses in individuals or relationships that had been fragile before the beginning of therapy. Intensive family therapy may also be difficult for family members with diagnosed psychological disorders. Family therapy may be especially difficult and stressful for children and adolescents who may not fully understand interactions that occur during family therapy. Adding individual therapy to family therapy for children and adolescents with the same therapist (if appropriate) or a therapist who is aware of the family therapy can be helpful.
Normal results vary, but in good circumstances, they include greater insight, increased differentiation of individual family members, improved communication within the family, loosening of previously automatic behavior patterns, and resolution of the problem that led the family to seek treatment.
Stepfamilies , which are increasing in prevalence, are excellent candidates for family therapy. Children and adolescents in stepfamilies often have difficulties adjusting, andparticipating in family therapy can be beneficial. Stepfamilies, increasingly referred to as “blended families,” experience unique pressures within each new family unit. Stepfamily researchers, family therapists, and the Stepfamily Association of America (SAA) view the term as inaccurate because it seems to suggest that members of a stepfamily blend into an entirely new family unit, losing their individuality and attachment to other outside family members. Because other family types (biological, single-parent, foster, adoptive) are defined by the parent-child relationship, the SAA believes that the term “stepfamily” more accurately reflects that relationship and is consistent with other family definitions. Viewing the stepfamily as a blended family can lead to unrealistic expectations, confused and conflicted children, difficult adjustment, and in many cases, failure of the marriage and family. Family therapy can help family members deal with these issues.
Children and adolescents and, in some cases even the parents, may be reluctant to participate in family therapy. Home-based family therapy has in the early 2000s become available as an option for families with severely disturbed adolescents and family members reluctant to see a therapist. In home-based therapy, a therapist or team of therapists comes directly to the family’s home and conducts therapy sessions there.
Blended family —A family formed by the remarriage of a divorced or widowed parent. It includes the new husband and wife, plus some or all of their children from previous marriages.
Differentiation —The ability to retain one’s identity within a family system while maintaining emotional connections with the other members.
Extended family field —A person’s family of origin plus grandparents, in-laws, and other relatives.
Family systems theory —An approach to treatment that emphasizes the interdependency of family members rather than focusing on individuals in isolation from the family. This theory underlies the most influential forms of contemporary family therapy.
Genogram —A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the family members understand their problem(s).
Homeostasis —The balanced internal environment of the body and the automatic tendency of the body to maintain this internal “steady state.” Also refers to the tendency of a family system to maintain internal stability and to resist change.
Identified patient (IP) —The family member in whom the family’s symptom has emerged or is most obvious.
Nuclear family —The basic family unit, consisting of a father, a mother, and their biological children.
Stepfamily —A family formed by the marriage or long-term cohabitation of two individuals, where one or both have at least one child from a previous relationship living part-time or full-time in the household. The individual who is not the biological parent of the child or children is referred to as the stepparent.
Triangling —A process in which two family members lower the tension level between them by drawing in a third member.
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American Association for Marriage and Family Therapy. 112 South Alfred St., Alexandria, VA 22314–3061. Web site: http://www.aamft.org/index_nm.asp.
International Family Therapy Association. Web site: http://www.ifta-familytherapy.org/about.htm.
Stepfamily Association of America. Web site: http://www.saafamilies.org.
Stepfamily Foundation. Web site: http://www.stepfamily.org.