March 2019 By

Family Therapy

​Family Therapy is a type of group psychotherapy that helps family members support one another, understand each other, and work through challenging situations. It is most appropriate for when psychopathology for any one individual is exacerbated by the interpersonal interactions in the family.

Family therapy is typically the mainstay treatment for children with disruptive behaviours.[1] However, there is strong evidence for the use of family therapy in schizophrenia and it is recommended in most clinical guidelines.[2] Family therapy is also a mainstay of treatment in anorexia nervosa.[3]

Definitions in Family Therapy

Definition and Questions to Think About Examples
Family A family is an open system composed of individuals that are connected in a specific way that mutually affects one another A family of a father, mother, son, and daughter.
Family Structure The family structure are the rules that govern a family’s behaviour.
  • What are the implicit rules?
  • Who is in charge?
  • What are the rules around showing affect (emotion)?
Family structure is that father is always in charge but never shows emotion. Mother will always be emotive and cry.
Subsystems Subsystems are the way in which families differentiate between each other and carries out its functions (e.g. — there is a “parent’s subsystem,” a “siblings subsystem”). Each individual is part of multiple subsystems in which they have different levels of power.
  • What are the different teams on the family?
Mother and father form the parent subsystem. Son and daughter form the sibling subsystem. Mother and daughter also form a subsystem of their own being the caretakers in the family.
Boundaries Boundaries are the rules that determine who participates in what subsystems, when, and how much. There are two types of boundaries: interpersonal and subsystems. Boundaries become problematic when they are unclear, or are in either extreme of being enmeshed or disengaged. The goal is for the family to develop clear boundaries. However, appreciate that the families are doing the best that they can under their circumstances.
  • Are the subsystems on either end of the spectrum?
  • Are they enmeshed (overly involved) or disengaged (no communication, either through affect or content)?
Father is disengaged from son and daughter's social life and shows no interest. Mother is overly enmeshed with daughter's friends and relationships to the point of being overbearing.
Power and Hierarchy The relative influence of each family member on an outcome.
  • Who does most of the talking?
  • Who decides who talks?
  • Who assigns tasks?
  • Who assigns qualities to the people in the room
  • Who looks to people for approval
Father speaks on behalf of the family most of the time and assigns tasks for the family. Mother will look to father for approval.
Alignment When two or more people share reciprocal benefits and bond in a positive way Son and daughter are aligned and bond positively. They support each other when needed.
Coalition An alliance of family members against another, that can lead to scapegoating Father, mother, and son have an alliance against daughter when she starts a new relationship.
Triangulation When one member of a two-member subsystem tries to distract by bringing in a third person Father and mother have an argument, but mother brings up the son in as a third party.

Evidence-based family therapies typically include psychoeducation, stress reduction, emotional processing, cognitive reappraisal, and structured problem solving. Family therapy can be thought of as occurring in 5 different stages.

Stage 1 (Joining)

The therapist joins with the family through:

  • Mimicry: matching the family’s mood, tempo, style of interaction
  • Maintenance: validation and highlighting the strengths within the family
  • Tracking: asking questions

Stage 2 (Identify)

The therapist identifies the problems, structures, and goals of the family.

Stage 3 (Shifts)

The therapist begins doing or observing the following:

  • Reframing: changing the problem from being within the individual to being between people. This allows you to focus on interpersonal solutions with multiple people rather than blaming one individual
  • Complementarity: Most issues and problems in life are often reciprocal and you can always reframe issues
    • e.g. — Upset parents say “Johnny is always being so immature.” As a therapist you could ask them — “What or who do you think is keeping him so young?”
  • Re-enactments: when you as the therapist see family dynamics happen in real-time during a session)
    • 3 steps to do as a therapist:
    • Watch the interaction
    • Decide which part of the interaction to highlight
    • Suggest an alternative to the interaction that occured
  • Boundary setting: changing the psychological distance between people through physical space

Stage 4 (Maintaining the Gains)

The therapist is maintaining the gains, supporting, and encouraging the changes in the family. Therapist is also keeping in mind that positives that the family notices can also be experienced as stressors.

Stage 5 (Ending)

When finishing therapy, therapist allows the family to start regulating themselves, and encourages reliance on the family members themselves.