Family therapy

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Introduction

Family therapy, also referred to as couple and family therapy and family systems therapy, and earlier generally referred to as marriage therapy, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view these in terms of the systems of interaction between family members. It emphasizes family relationships as an important factor in psychological health. As such, family problems have been seen to arise as an emergent property of systemic interactions, rather than to be blamed on individual members.

Family therapists may focus more on how patterns of interaction maintain the problem rather than trying to identify the cause, as this can be experienced as blaming by some families. It assumes that the family as a whole is larger than the sum of its parts.

Most practitioners are "eclectic", using techniques from several areas, depending upon the client(s). Family therapy practitioners come from a range of professional backgrounds, and some are specifically qualified or licensed/registered in family therapy (licensing is not required in some jurisdictions and requirements vary from place to place). In the UK, family therapists are usually psychologists, nurses, psychotherapists, social workers, or counselors who have done further training in family therapy, either a diploma or an M.Sc..

Multicultural and inter-cultural approaches are being developed.

Family therapy has been used effectively where families, and or individuals in those families experience or suffer:

• serious psychological disorders (e.g. schizophrenia, addictions and eating disorders);
• interactional and transitional crises in a family’s life cycle (e.g. divorce, suicide attempts, dislocation, war, etc.)
• as a support of other psychotherapies and medication.

History

The origins and development of the field of family therapy progressed in two distinct phases over the past century. This can be considered as a natural outcome of the environmental perspective, more succinctly defined by the neurologist, John Delgado, as “cerebral and extra cerebral”. In this analysis, the “human mind develops as the brain processes and stores the multiple inputs triggered both internally and externally.” Information, attitudes and perceptions are stored to be used in the individual’s framework of reality. In this context, pathology lies both within and outside of the mind of the individual. This pertains to pathologies in families as well.

The time line for this change of paradigm in the psychotherapy approach evolved from the Freudian tradition centered on the dyadic relationship between patient and doctor. Pathology was thought to be within the individual. It was not until around the 1950s that insights started to come out of work done with families of schizophrenic patients. The change of perspective away from Freudian theory and toward a systems approach has been unfolding since then.

“There are two rivers of ideas flowing through the volume. The first, as I have noted, builds on Bateson and is concerned with assembling the elements of a unified theory of family function and family therapy.” George Bateson used the term “bicameral format” to refer to the dual nature of human perception through the use of two eyes, two sides of the brain, two hands and etc. The point of this was that it was possible to have two different points of view and both could be right. His idea of using two rooms to view family interactions also called the “two chamber framework”

What was the landscape that brought on this sensible concept? In order to get the full picture, it is helpful to look at why the former system had become outmoded. “The figures who seem to have had the most impact on the family field in its infancy were, oddly enough, not so much psychotherapists but such scientists as information theorist Claude Shannon, cyberneticist Norbert Wiener, and general systems theorist Ludwig von Neuman. One must add to this list George Bateson, whose synthesizing genius showed how ideas from such divergent sources could be useful to the understanding of communication processes, including those associated with psychopathology. Bateson was also one of the first to introduce the idea that a family might be analogous to a homeostatic or cybernetic system.”

Bateson was married to the American cultural anthropologist Margaret Mead between 1936 and 1950. Margaret Mead had been married twice before Bateson — first to Luther Cressman, who was theological student during the marriage (and later became an anthropologist himself), and second to Reo Fortune. Bateson and Mead had a daughter Mary Catherine Bateson, who also became an anthropologist. Their granddaughter, Sevanne Margaret Kassarjian, is a stage and television actress who works professionally under the name Sevanne Martin.

Margaret Mead was an influential figure in systems theory.

One of the threads that connects Bateson's work is an interest in systems theory and cybernetics, a science he helped to create as one of the original members of the core group of the Macy Conferences. Bateson's take on these fields centers upon their relationship to epistemology, and this central interest provides the undercurrents of his thought. His association with the editor and author Stewart Brand was part of a process by which Bateson’s influence widened — for from the 1970s until Bateson’s last years, a broader audience of university students and educated people working in many fields came not only to know his name but also into contact to varying degrees with his thought.

Two distinct generations of thought emerged from this. The change can be characterized as moving from a linear framework to a complex framework. “In the field of mental health there has been a growing disenchantment with the linear causality of Western thought. Mental illness has traditionally been thought of in linear terms, with historical, causal explanations for the distress.” It was thought that the symptoms were the result of an illness or biological malfunction. The people charged with a cure were doctors and the setting for their work was a hospital. The psychodynamic model of the nineteenth- century added trauma from a patient’s past to the list of possible causes. To put it simply, distress was thought to arise from biological or physiological causes or from repressed memories. The use of the two room therapy model introduced a new “window” to see through. By watching families interact with the patient in a room separated by a one way window, it became clear that patients behaved differently when in the dynamics of their family. The interactions within the family unit created “causal feedback loops that played back and forth, with the behavior of the afflicted person only part of a larger, recursive dance.”

Bateson persisted in attempting to redefine the dynamics of human interaction and made a distinction between physical objects and living forms. He denounced the Newtonian world view that suggested that everything in the physical universe could be compared with the movement of a clock i.e. a linear process of predictability. Lynn Hoffman wrote in her book, Foundations of Family Therapy, “I first stumbled upon family research in Palo Alto in 1963. There, at the Mental Research Institute, I began to see from the studies that had come out of George Bateson’s 1952 – 1962 research project on communication that a change in family depended very much on the interplay between deviation and the way deviation was kept within bounds.” (Hoffman, p. 11) Hoffman became intrigued by the role that deviation plays in family systems and recognized the fact, that in some cases, deviant behavior was useful and sometimes necessary to keep a family system moving forward from one generation to the next.

The “double bind” hypothesis was coined in Bateson’s famous paper, “Toward a Theory of Schizophrenia” published in 1956. “Double blind” describes a context of habitual communication impasses imposed on one another by persons in a relationship system.” . This form of communication depicts a type of command that is given on one level and nullified on another level. It is a paradox that creates constant confusion and unresolved interpretations. An example is when an irritated mother tells her child to go to bed so they can get enough sleep for school tomorrow when, in fact, she just wants some private space or a break from the child. Depending on the level of deceit (often called a white lie) both parties are unable to acknowledge what the other is really saying or feeling. This is a highly simplified example but illustrates how commonly the “double blind” is used, even in “normal” family life.

The approach of the early family researchers was analytical and, as such, focused on the patient only. Family members and others in the individual’s social circle were not allowed anywhere near as they might “taint” the pureness of the therapy. It was by chance that Bateson and his colleagues came across the family’s role in a schizophrenic patient’s illness. Once Pandora’s Box was open, other researchers began to experiment and find similar outcomes. In the 1960s many articles poured out with examples of successful strategies of working with schizophrenic patients and their family members. The mother’s role was usually considered to play a central role in the breakdown of communication and the underlying controls that were in place. Researchers Jackson, Weakland, Frye and Yalom are some of the names that are also identified with producing books and articles on the subject.

The original framework for the “double bind” was a two-person or “dyadic” arrangement. Criticism of the dyadic approach appeared in an essay by Weakland titled, The Double Bind: Hypothesis of Schizophrenia and Three Party Interaction” in 1960. Further articles in the 1970s by both Weakland and Bateson suggest that this concept referred to a much broader spectrum than schizophrenias. Bateson began to formulate a systems approach which factored in the relationships of family as a coalition. He used an analogy from game theory that described repeated patterns found in families with a schizophrenic member. The pattern that emerged was that “no two persons seemed to be able to get together without a third person taking part.”

The game theory Bateson drew from was based on Theory of Games by Von Neuman and Morgenstern. (Hoffman, p. 25) In this theory, the tendency of “winning” personalities is to form coalitions. This rule, however, did not apply when the group had three or five members. Bateson found in his research that “no two members ever seemed able to get together in a stable alignment” in schizophrenic families.

A game of imperfect information (the dotted line represents ignorance on the part of player 2)

The next logical progression from this process was the development of consideration of families as a “cybernetic” system. In Strategies of Psychotherapy, Haley agrees with Bateson’s conclusion that schizophrenic families exhibit consistent use of “disqualifying messages” or “double bind” communication style. He added to this the idea that “people in a family act to control the range of one another’s behavior.” He based much of his argument for the two levels of disconnected communication and need to control on Russell’s “theory of logical types”.

In the 1930s, Bateson, as a young cultural anthropologist, studied the Iatmul culture in New Guinea. From his observations, he coined the word, “schismogenesis”. “This word described the type of escalation found throughout the natural world and exemplified by the vicious circle. . . Kenneth Boulding called this “dominance – submission cycle” in his essay entitled, Conflict and Defense, published in 1962.

The role of mathematics and statistics as well as the study of other disciplines like anthropology, game theory, biology, also were included in the body of information used to formulate the dynamic or cybernetic theory of family systems. In 1939 British political scientist and mathematician, Richardson, wrote the book, The Statistics of Deadly Quarrels. In this essay, he depicted the process leading to armed races and international hostilities using statistical devises. He utilized a graph system much like an economic supply and demand chart, to show the escalation of hostilities and the point where hostilities ended (called the ‘”equilibrium point”).

Bateson also employed the methods of Richardson but disagreed with the idea of an equilibrium point. Instead he concluded that there was a “dual need for tension arousal followed by tension reduction . . . " . In other words, he did not leave it to statistical law but rather to the natural interactions found within biological life as evidenced by his research early in his life. This framework hinged greatly on balances of power, the nature of rivalry and the Mrole of hierarchical order within and between groups, families and individuals.

Salvadore Minuchin published Families and Family Therapy in 1974. His theory is based on “structural family therapy” which is a process that considers the feedback between circumstances and the shift that occurs following the feedback. In other words, “By changing the relationship between a person and the familiar context in which he functions, one changes his objective experience.” The therapist enters into the family setting and becomes an agent of change. The introduction of this new perspective begins a transforming and healing process as each member of the family adjusts their world view vis-à-vis the new information.

Minuchin’s structural family therapy considered this mechanism with the addition of also recognizing that the family past manifests in the present. He wisely set out to benchmark a “model of normality” derived from examination of families in different cultures. His goal was to identify healthy patterns shared by all families without regard of their culture. Minuchin wrote, that in all cultural contexts “the family imprints its members with selfhood.” (Minuchin, p47) The changes brought about in the Western cultural sphere since the urban industrial revolution has brought forced, rapid change in the patterns of common family interactions. Economic demands have placed both parents out of the home leaving children to be raised at school, day care, or by peers, television, internet, and computer games. “In the face of all these changes, modern man still adheres to a set of values." He went on to say that these changes actually make the role of the family as a support even more vital to current society than ever before. When he was writing this book, the forces of change he was referring to was the women’s liberation movement and conflicts from the “generation gap”. The world has continued to unfold since then in a way that even Minuchen wouldn’t have been able to foresee. Despite this, his work has been and continues to be relevant and important to inform the efforts of practitioners in the field today.

Interest in the mental illness of schizophrenia in the 1950s prompted financial resources for research from the National Institute of Mental Health. A new wing was designed at Bethesda, Maryland and designated for psychiatric research. Murray Bowen was hired at this new research facility from his post at the Menninger Clinic in Topeka, Kansas. He was of the opinion that the predominant theory in practice, the Freudian theory, was too narrow. “He had an idea that the basic unit of emotional functioning might not be the individual, as previously thought, but the nuclear family.”

Based on this, Bowen suggested that a new way of looking at and analyzing the interactions within families was needed. He called this method “systems thinking”. Bowen’s theory became a catalyst for the paradigm shift taking place in the field of mental health and family therapy. Some of the underlying assumptions are based on a few pivotal concepts. An example of one such principle is the “struggle that arises out of the need to strike a balance between two basic urges: the drive towards being an individual – one alone, autonomous – and the drive towards being together with others in relationship” . Bowen’s theory focused on the need for the two forces to find a point of balance. The balancing point centers on the role of individuals in families and how to manage their “togetherness” As individuals become more emotionally mature, their ability to find the proper balance in the family increases.

File:Family therapy.jpg

Murray Bowen's most important work Family therapy in clinical practice, Aronson edition 1994

Another underlying assumption in Bowen’s theory rests on the concept that “individuals vary in their ability to adapt – that is, to cope with the demands of life and to reach their goals” (Gilbert, p18). In high functioning families, the amount of fused emotional attachment is very slight. Bowen’s theory emphasizes the evolutionary process of brain development. Evolution of human behavior has parallels with other forms of biological life. Systems thinking, in Bowen family systems theory, postulates that “as a product of evolution, the emotional part of man’s nervous system is more like those of other forms of life than it is different from them” (Gilbert, p27) The neuroanatomical studies of man’s “triune” brain by Dr. Paul MacLeon provided more support for his theories.

It is also important to mention the importance of “triangulation” when considering Bowen’s theory. Essentially this is based on his analysis that ‘human emotional systems are built on triangles” Magoroh Maruyama defined the essential elements of any living system as “morphostasis” and “morphogenesis”. (Hoffman, p50) Morphostasis refers to the need for a system to maintain constancy. Morphogensis is the process by which a system allows “positive feedback” to bring needed changes for survival to a system. Ironically, there were counterbalancing critiques from other theorists that believed that positive feedback loops were actually destructive to a system. The main idea behind this point of view was that the change created by new feedback loops introduced chaos and collapse. Maruyama counterbalanced this claim by devising a complex explanation of counterbalancing forces inherent in a natural process of change that required both positive and negative “mutual causal loops”. Examples of this, attributed to the cybernetics theme, are available in macro and micro systems of organization. In a city, the population, migration level, sanitation facilities, level of modern development, climate and common diseases can become positive and negative feedback loops that impact the increase or decrease in the population.

Methodology

It uses a range of counseling and other techniques including:

• psychotherapy
• systems theory
• communication theory
• systemic coaching

The number of sessions depends on the situation, but the average is 5-20 sessions. The basic theory of family therapy is derived mainly from object relations theory, cognitive psychotherapy, systems theory and narrative approaches. Other important approaches used by family therapists include intergenerational theory (Bowen systems theory, Contextual therapy), EFT (emotionally focused therapy), solution-focused therapy, experiential therapy, and social constructionism.

A family therapist usually meets several members of the family at the same time ("conjoint family therapy" is used in the approach of Virginia Satir.) This has the advantage of making differences between the ways family members perceive mutual relations as well as interaction patterns in the session apparent both for the therapist and the family. These patterns frequently mirror habitual interaction patterns at home, even though the therapist is now incorporated into the family system. Therapy interventions usually focus on relationship patterns rather than on analyzing impulses of the unconscious mind or early childhood trauma of individuals as a Freudian therapist would do.

Family therapy is really a way of thinking, an epistemology rather than about how many people sit in the room with the therapist. Family therapists are relational therapists; they are interested in what goes between people rather than in people.

Depending on circumstances, a therapist may point out to the family interaction patterns that the family might have not noticed; or suggest different ways of responding to other family members. These changes in the way of responding may then trigger repercussions in the whole system, leading to a more satisfactory systemic state.

A novel development in the field of couples therapy in particular, has involved the introduction of insights gained from affective neuroscience and psychopharmacology into clinical practice. There has been particular interest in use of the so-called love hormone – oxytocin – during therapy sessions, although this is still largely experimental and somewhat controversial.

In the United States

Prior to 1999 in California, counselors who specialized in this area were called Marriage, Family and Child Counselors. Today, they are known as Marriage and Family Therapists, (MFTs) and work variously in private practice, in clinical settings such as hospitals, institutions, or counseling organizations.

MFTs are often confused with Clinical Social Workers (CSWs). The primary difference in these two professions is that CSWs focus on social relationships in the community as a whole, while MFTs focus on family relationships.

A master's degree is required to work as an MFT. Most commonly, MFTs will first earn a B.S. or B.A. degree in psychology, and then spend 2 to 3 years completing a program in specific areas of psychology relevant to marriage and family therapy. After graduation, prospective MFTs work as interns.

Requirements vary, but in most states about 3000 hours of supervised work as an intern are needed to sit for a licensing exam. MFTs must be licensed by the state to practice. Only after completing their education and internship and passing the state licensing exam can they call themselves MFTs and work unsupervised.

License restrictions can vary considerably from state to state. In Ohio, for example, Marriage and Family Therapists are currently not allowed to diagnose and treat mental and emotional disorders, practice independently, or bill insurance. MFTs in Ohio face a long road of fighting for equality.

There have been concerns raised within the profession about the fact that specialist training in couples therapy – as distinct from family therapy in general - is not required to gain a license as an MFT or membership of the main professional body (AAMFT).

Since issues of interpersonal conflict, values, and ethics are often more pronounced in relationship therapy than in individual therapy, there has been debate within the profession about the values implicit in the various theoretical models of therapy and the role of the therapist’s own values in the therapeutic process, and how prospective clients should best go about finding a therapist whose values and objectives are most consistent with their own. Specific issues that have emerged have included an increasing questioning of the longstanding notion of therapeutic neutrality, a concern with questions of justice and self-determination, connectedness and independence, ‘functioning’ versus ‘authenticity’, and questions about the degree of the therapist’s ‘pro-marriage/family’ versus ‘pro-individual’ commitment.

Founders and key influences

Some key developers of family therapy are:

• Nathan Ackerman (psychoanalytic)
• Gregory Bateson (1904 – 1980) (cybernetics)
• Insoo Kim Berg (solution focused therapy)
• Ivan Boszormenyi-Nagy (Contextual therapy, relational ethics)
• Murray Bowen (systems theory)
• John Bradshaw (author) (systems theory)
• Milton H. Erickson (hypnotherapy, strategic therapy)
• James Framo (object relations theory)
• John Gottman (marriage)
• Jay Haley (strategic therapy, communications)
• Lynn Hoffman
• Don D. Jackson
• Susan Johnson (emotionally focused therapy)
• Walter Kempler (Gestalt psychology)
• George L. McGhee (MFT laws and ethics founder CAMFT)
• Salvador Minuchin (structural)
• Virginia Satir (communications and experiential)
• Robin Skynner (Group Analysis)
• Carl Whitaker (Family, Systems, Co-Therapy)
• Michael White (narrative therapy)
• Lyman Wynne (Schizophrenia, pseudomutuality)

See also

• Child abuse
• Conflict resolution
• Domestic violence
• Dyadic Developmental Psychotherapy
• Family
• Genogram
• Group therapy
• Interpersonal relationship
• Intimate relationship
• Marriage
• Mediation
• Mental health professional
• Relationship counseling
• Relationships Australia

External links

• American Association for Marriage and Family Therapy
• American Family Therapy Academy
• Association for Family Therapy and Systemic Practice in the UK
• Australian and New Zealand Journal of Family Therapy
• Bowen Theory
• California Association of Marriage and Family Therapists
• European Family Therapy Association
• International Family Therapy Association
• Historical overview of field; Therapist profiles; Timeline
• Harvard Mental Health Letter article on Couple Therapy

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