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.

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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]

  • Domestic violence is a contraindication to family therapy, as attempts to implement therapy during ongoing violence may increase the risk of serious harm.[4]

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.

The therapist joins with the family through:

  • Introducing yourself
  • Mimicry: matching the family’s mood, tempo, style of interaction
  • Maintenance: validation and highlighting the strengths within the family
    • “What are you interested in? What does dad like to do, what are their interests?”
    • If multiple siblings:
      • “Who do you guys all go to if you want to ask for a favour?”
      • “Who is better at asking for stuff?”
  • Tracking: asking questions
  • In the initial stages, it is important to get a good “flow” rather than focusing the content

The therapist now identifies the problems, structures, and goals of the family by:

  • Getting a family genogram to see the family structure
  • Asking: what brings them to therapy?
  • Review goals for the family:
    • Make sure that the goal is for the family, not one individual person (i.e. - it is not: “I want dad to stop yelling”), goals are something the whole family can agree on (e.g. - “less yelling between family members” or “not speaking for someone else”, or “taking turns listening”)

The therapist begins doing or observing the following, and identifying major conflicts in the family by:

  • 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 occurred
  • Boundary setting: changing the psychological distance between people through physical space
  • As conflicts are identified, the therapist will:
    • Challenge family to get around defenses and come up with solutions
    • Meet with subgroups of the family separately

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.

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

  • Has the presenting complaint improved?
  • Is the family satisfied with what they have gotten?
  • Does the family have an understanding of what they were doing that wasn’t working?
  • Have family members developed and improved relationships outside the immediate family context as well as within it?
  • Do they see each other as others see them?

The McMaster approach has several principles including:

  1. Communication “Was the message received as sent?” (think about how often text messages can be misunderstood!)
    • Is the message actually getting across to the children way you intend it to? Are other people interpreting it as being invalidating? (e.g. - Mom: “you have to stop doing this.”, Child: “stop yelling”, Mom: “I’m not yelling”) Could the invalidation worsen the symptoms? (e.g. - saying “You’re fine, you’re fine.“ to child reporting symptoms)
    • If the child has autism spectrum or other intellectual disability, maybe they cannot understand what is being communicated.
  2. Affect
    • What is being conveyed?
    • Is everyone in the family reading one another’s affect well?
    • What is the emotional temperature?
  3. Problem Solving
    • Did the problem get resolved?
  4. Roles (all family have roles, either formally or informally)
    • Formal Roles:
      • Mother
      • Father
      • Child
    • Informal Roles:
      • Sixteen-year-old who is a parentified child (took on more adult responsibilities)
      • Mother who confides in her son, instead of her husband (son becomes an informal spouse)
    • Are these roles adaptive or maladaptive? (Lots of informal roles are adaptive)

Narrative family therapy is another modality of family therapy that attempts to separate a person from the problematic behaviour. For example, a family might be concerned about an “angry child,” in narrative therapy, the following approach is taken:

  • Re-authoring:
    • Asking the individual: What is your story?
    • Asking the other family members “what did you think of that as you heard the story?”
  • Deconstruction:
    • Breaking down the symptoms from a curious stance
    • Where is it happening? At home? School? With friends? With parents?
    • Are there unique outcomes? (i.e. - situations/outcomes opposite of “getting angry”)
      • Deconstruct this to understand what went right
    • Externalization:
      • Lets imagine this fear/anger/etc. was separated from you. How could it influence you?
      • Imply: “Jeremy, tell me about this anger that sometimes gets in your way.”
      • Explicitly: “How does your anger/OCD/eating disorder get in the way?”
    • Reflections:
      • A team behind a two-way mirror (with family consent of course) talks about the observations that they saw
      • Family listens to the second team behind a mirror
      • Allows a space for family to hear from a team that is not involved directly
  • Emphasize individual maturation in context of family systems, free from unconscious patterns
  • Establish intimate bond with each family member, alternate with member exchanges with each other
  • Clarity of communication and honestly admitted feelings
  • Family members encouraged to change seats in interaction
  • Use of metaphor, body language, parapraxes (Freudian slips)
  • Family sculpting, family members physically arrange one another in tableaus depicting relationships
  • Therapist subjective responses to family, feedback loops
  • Also called Family systems therapy
  • Hallmark is differentiation from family and ability to be true selves
  • Assessed on degree of enmeshment vs. degree of ability to differentiate and analysis of emotional triangles
  • Emotional triangle: closeness of two members either as love or repetitive conflict excludes the third member
  • Stabilize the “hot” triangle producing symptoms and work with psychologically available members
  • Genogram – historical survey of family going back several generations
  • Families viewed as single, interrelated systems assessed in terms of significant alliances, hierarchies of power, clarity and firmness of boundaries, family tolerance for one another
  • Concurrent individual and family therapy

Comparison of Family Therapies

Model Key point Features Therapist Role
Psychodynamic-Experiential • Focus is on individual maturation in context of family system • Clarity of communication and honesty are priorities • Establish intimate bond with each family member, use metaphors and body language
• Uncover unconscious pattern of family relationships
Family Systems (Bowen Model) • The individual differentiates themselves from their family of origin
• Focus on increasing levels of differentiation (making changes for the self rather than trying to change others)
• Uses the genogram (a historical survey of the family)
• “Hot triangle” • Shift/stabilize the hot triangle that is producing symptoms
• Therapist is neutral and limits emotional contact with family members
Structural (Minuchin) • Family as single, interrelated systems, characterized by alliances and splits, hierarchy of power. • Emphasizes on clarity and firmness of boundaries between generations • Family mapping
• Giving set of instructions to enhance communication
• Goal is to obtain clarity
General Systems • Families are systems
• Every action produces a reaction in others
• Overlaps with Bowen and Minuchin models
• Families have external boundaries and internal rules
• Every family member plays a “role” (e.g. - spokesperson, persecutory, victim, etc…)
• Family members may scapegoat another member by blaming them for the families problems
• Insight and improved communication
  • Avoid being the conduit for information, ask they family to speak to each other and ask the right questions
    • “You’re looking at me as you’re talking to your dad, can you talk to him directly?”
  • Set clear boundaries in the session, and be in charge
  • Block cross arguments between members by allowing each person to speak at one time
  • Interrupt when one person is speaking for other people (but don't necessarily say that is the reason for why you are interrupting)
  • Highlight the processes in therapy