Family therapy is a form of psychotherapy that involves all the members of anuclear or extended family. It may be conducted by a pair or team of marriageand family therapists who have come from a wide variety of educational backgrounds including psychology, psychiatry, social work, nursing, pastoral counseling and education.
In many cases the marriage and family therapy team consists of a man and a woman in order to treat gender-related issues or serve as role models for family members. Although some types of family therapy are based on behavioral or psychodynamic principles, the most widespread form is based on family systemstheory. This approach regards the family as a whole as the unit of treatment,and emphasizes such factors as relationships and communication patterns rather than traits or symptoms in individual members.
Family therapy is a relatively recent development in psychotherapy. It beganshortly after World War II, when doctors treating schizophrenic patients noticed that the patients' families communicated in disturbed ways. The doctors also found that the patients' symptoms increased or decreased according to thelevel of tension between their parents. These observations led to the consideration of a family as a system with its own internal rules, patterns of functioning, and tendency to resist change.
The therapists started to treat the families of schizophrenic patients as whole units rather than focusing on the hospitalized member. They found that inmany cases the family member with schizophrenia improved when the "patient" was the family system. (This should not be misunderstood to mean that schizophrenia is caused by family problems, although family problems may worsen the condition.) This approach of involving the entire family in the treatment planand therapy was then applied to families with problems other than the presence of schizophrenia.
Family therapy is becoming more common as changes in American society are reflected in evolving family structures. The treatment philosophy has led to thedevelopment of couples therapy, which treats relationship problems between partners; and to the treatment of groups that resemble families (such as religious communities).
Family therapy tends to be brief (averaging only about 9 sessions)--requiringless time than the average individual treatment of 13 sessions. Nearly 65.6%of the cases are completed within 20 sessions, 87.9% within 50 sessions. Thetreatment focuses on resolving specific problems such as eating disorders, difficulties with school, or adjustments to bereavement or geographical relocation. Research indicates that marriage and family therapy is more effective than individual treatment for many mental health problems such as schizophrenia, alcoholism and drug abuse, children's conduct disorders, adolescent drug abuse, anorexia in young adult women, childhood autism, chronic physical illness in adults and children, and marital distress and conflict.
In family therapy sessions, all members of the family and both therapists (ifthere is more than one) are present at most sessions. The therapists seek toanalyze the process of family interaction and communication as a whole; theydon't take sides with specific members. They may make occasional comments orremarks intended to help family members become more conscious of patterns orstructures that had been previously taken for granted. Family therapists whowork as a team model new behaviors for the family through their interactionswith each other during sessions.
Family therapy is based on family systems theory, which understands the family to be a living organism that is more than the sum of its individual members. Family therapy uses "systems" theory to evaluate family members in terms oftheir position or role within the system as a whole. Problems are treated bychanging the way the system works rather than trying to "fix" a specific member. Family systems theory is based on several major concepts:
The "identified patient" is the family member with the symptom that has brought the family into treatment. Family therapists work hard to keep the familyfrom picking on the identified patient or using him or her as a way of avoiding problems in the rest of the family.
The family as a whole usually tries to maintain its organization and functioning, and will tend to resist change. The family therapist can use this concept to explain why a certain family symptom has surfaced at a given time, why aspecific member has become the identified patient, and what is likely to happen when the family begins to change.
The family therapist will also work with the "extended family field"--the nuclear family plus grandparents and other members of the extended family. Looking at the extended family can help explain the intergenerational transmissionof attitudes, problems, behaviors, and other issues.
In treating the family, the therapist will look at how well each family member maintains 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 everyone still feels they are an important part ofthe family.
Family therapists believe that emotional relationships in families usually involve three people. Whenever any two people 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 the family status quo. Common family triangles include a child and both parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.
In some instances the family may have been referred to a specialist in familytherapy by their pediatrician or other health care provider. It is estimatedthat as many as 50% 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'sneed for therapy.
Family therapy is often recommended in the following situations:
- During treatment of a patient with schizophrenia or multiple personality disorder(MPD) to help other family members understand the disorder and adjust to theperson's psychological changes
- Families with trouble across generations, such as problems caused by parents sharing housing with grandparents or children being raised by grandparents
- Families who deviate from socialnorms (common-law relationships, gay couples rearing children) who may be troubled by outsiders'attitudes
- Families with members from different racial, cultural, or religious backgrounds
- Families who are "picking on" one member or undermining the treatment of a member in individual therapy
- Families who seem inextricably tied to problems of an identified patient
- Blended families with adjustment problems
Some families are not considered suitable candidates for family therapy, including:
- Families in which one or both of the parents is psychotic, antisocial or paranoid
- Families whose cultural or religious values are opposed to, or suspicious of psychotherapy
- Families with members who can't participate in treatment sessions because of physical illness or similarlimitations
- Families with members with very rigid personality structures who are at risk for an emotional or psychological crisis
- Familieswhose members can't or won't be able to meet regularly for treatment
- Unstable families or those on the verge of breakup.
The family therapist will usually evaluate a family for treatment by scheduling a series of interviews with the members of the immediate family, includingyoung 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, patterns of dominance and submission, the roles played by family members, communication styles, and the locations of emotional triangles. They will also note whether these patterns are rigid or relatively flexible.
Preparation also usually includes drawing a genogram, which is a diagram thatdepicts significant persons and events in the family's history. Genograms also include annotations about the medical history and major personality traitsof each member. Genograms help in uncovering 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 presentsituation.
The chief risk in family therapy is the possible unsettling of rigid personality defenses in individuals, or couple relationships that had been fragile before the beginning of therapy. Intensive family therapy may also be difficultfor psychotic family members.
The federal government has designated marriage and family therapy as a core mental health profession along with psychiatry, psychology, social work and psychiatric nursing. Currently, 42 states regulate the profession by licensingor certifying marriage and family therapists; many other states considering licensing bills.