Family Therapy

Nichols and Schwartz (1998)

I. The Foundations of Family Therapy - Chapter 1 - Outline by David Peers

A. The myth of the hero

1. The individual is unique and autonomous

2. Breaking free from childhood

3. The myth of rising above the human condition and individuation

4. Individuals are sustained by interpersonal relationships

5. Families are both withholding and uplifting - sometimes at the same time

B. Psychotherapeutic sanctuary

1. Therapy in isolation or in groups?

2. Freud and Rogers emphasized private patient/therapist relations

3. Freud: real family who needs it? The use of transference - the therapist as parent

4. Rogers: exploration of self and self - actualization. The need for approval

5. Rogers: support, unconditional positive regard, and the art of listening

C. Family vs. Individual therapy

1. Both are approaches to treatment and understandings of human behavior

2. Individual therapy

a. Concentrated focus

b. Internalization of personal dynamics

3. Family therapy

a. External focus

b. Changing organizations - change on the entire family, systemic

4. Are we separate entities or embedded in a network of relationships?

D. Psychology and social context

1. Family therapy flourishes because of success and recognition of interconnectedness

2. Is psychotherapy intrapsychic or interpersonal? Perhaps both or neither?

3. Family therapy as an orientation rather than a technique

4. Uncovering family influences

5. Individuals within a system

E. The power of family therapy

1. Evolution from 1950’s to today

2.1975 - 1985 as golden age - shared optimism and common purpose

3. Problems may originate from interaction so change focuses on interactions

4. Questions:

a. Constructivist notions?

b. Narrative therapy?

c. Integrative techniques?

d. Social issues?

F. Contemporary cultural influences

1. Managed health care

a. Crisis intervention versus ongoing personal exploration?

b. Confidentiality?. Prejudicial employers?

2. Postmodern skepticism

a. Integrated schools of thought

b. Approaches to clients or clients to approaches?

G. Thinking in lines vs. Thinking in circles

1. Cause and effect perspectives - unilateral influence

2. Circles of thought as empowering

3. Transforming interactions

4. Major advantage of family therapy: works directly on unhappy relationships

5. The difficulty of change

6. Personal participation in problems

7. Circular problems - the cause is the result and the result the cause

8. Learning life’s painful lessons and understanding the family’s story

II. The Evolution Of Family Therapy - Chapter 2 Outlined by Lori Rice

A. The undeclared war

1. 1950’s - - change in one person changes the system

2. Brown research with schizophrenic patients returning home (1959)

3. Current psychiatric hospital therapy and possible family segregation

B. Small group dynamics

1. William Mcdougall - group mind

2. Lewin - group is more than the sum of its parts - - group discussions superior to individual instruction for changing ideas/behavior

3. Bion (1948) fight - flight, dependency, and pairing

4. Process/content in group dynamics

5. Role theories

6. Similarities between group and family therapies

C. Child guidance movement

1. Scholars publishing more than clinicians

2. Movement assumption: Emotional problems begin in childhood, therefore treat the child

3. Shift to include families in treatment, but typically blame parents for child’s problems Fromm - Reichmann’s schizophrenogenic mother

D. The influence of social work

1. Family casework - families must be considered as units

2. Social workers among most influential in family therapy

E. Research on family dynamics and the etiology of schizophrenia

1. Gregory Bateson

a. Researched communication among animals

b. Functions of communication: report and command, metacommunication

c. Bateson joined by others to investigate conflicts between messages and qualifying messages

d. Double bind

2. Theodore Lidz

3. Lyman Wynne - rubber fences, pseudomutuality, and pseudohostility

4. Role theorists marriage counseling

III. Early Models And Basic Techniques: Group Process And Communications Analysis - Chapter 3 — Outlined by Sarah Sifers.

A. Family therapy has a history of being condescending

B. Sketches of leading figures

1. Group family therapy (group) - Bell, Dreikurs, Midelfort, Foulkes, Skynner

2. Communications family therapy (communication) - Jackson, Haley, Bateson, Satir

C. Theoretical formulations - group

1. Group/family leaders

2. Family defense mechanisms

3. Subgroups

4. Field theory (Lewin) - conflict is an ‘inevitable part of group life

5.Role theory - every group has roles that have "rules" for conduct (intra - and inter - role conflict, fit between personality and role)

D. Theoretical formulations - communications

1. Black box - disregards individual complexity to focus on input and output (communication)

2. Circular causal (disregard past)

3. Syntax - - ways words are put together to make sentences

4. Semantics - clarity, private or shared communication systems, concordance versus confusion

5. Pragmatics - behavioral effects of communication

6. People are always communicating

7. Re ort - (content) conveys information

8. Command - statement about the definition of the relationship

9. Family rules - description of regular interactions

10. Family homeostasis - acceptable behavioral balance within the family

11. Complementary relationships - based on differences that fit together

12. Symmetrical relationships - based on equality and mirroring of behavior

13. Communication punctuation - organizes behavioral events and reflects observer bias

14. Negative feedback loop - perpetuates problems by maintaining status quo

15. Positive feedback loop - alters the system to accommodate novel input

E. Normal family development

1. Group

a. Instrumental and expressive leaders

b. Three phases of group development: inclusion, control, affection

c. Cohesiveness

d. Need compatibility

2. Communications

a. Feedback loops

b. Normal families become unbalanced during transitions in family life cycle

F. Development of behavior disorders

1. Group - symptoms as products of disturbed and disturbing group processes - if needs continue to go unmet, symptoms may be perpetuated into a role and group organizes around a "sick" member

2. Communications - "identified patient" as a role with counterroles and complimentary roles that maintain the system - - - caused by pathological communication such as paradoxical injunctions/ double binds

G. Goals of therapy

1. Group - individuation of group members, personal growth, and improved relationships

2. Communications - change/prevent maladaptive interactions viii.

H. Conditions for behavior chang

1. Group - help family members talk to each other, concentrating more on process than content, then explore those feelings

2. Communications - making covert messages behind symptoms overt. Therapist may manipulate the family be prescribing the symptom or therapeutic double binds, introducing positive feedback loops

I. Techniques of group family therapy

1. Therapist as process leader

2. Stages - child - centered, parent - centered, family - centered

3. Types of therapy - multiple group therapy, multiple impact therapy, network therapy

4. Resistance - anything that interfered with balanced self - expression

J. Techniques of communications family therapy

1. Structured family interview (5 tasks)

2. Teaching rules of clear communication - (using "I", stating facts, talking to - not about)

3. Used family’s moment to circumvent resistance

4. Therapist as referee and reframer, making implicit rules explicit and using therapeutic paradox

K. Lessons from early models

1. Group - group dynamics, roles, process/content distinction, free and open discussion, reflective interpretations, connective interpretations, reconstructive interpretations, normative interpretations, networking, confronting, caveat - families aren’t egalitarian

2. Communications - double bind, metacommunication, homeostasis, rules, feedback loops, cybernetics, altering patterns of communication, paradoxical directives, symptoms - focused, focus on marital pair

L. System’s anxiety

1. Therapists viewed family as being to blame for a "victim’s" illness and were, therefore, the enemy

2. Cybernetics and general systems theory helped clinicians understand families, but tend to dismiss selfhood as an illusion

M. Stages of family therapy (checklists in text)

1. Initial call - keep it short

2. First interview - build alliance and hypothesize

3. Early phase of treatment - refining hypothesis and beginning to work on problems

4. Middle phase of treatment - family begins to take more active role

5. Termination - review and consolidate

N. Family assessment

1. Presenting problem

2. Understanding referral route

3. Identifying systemic context (interpersonal context of presenting concern)

4. Stages of life cycle

5. Family structure

6. Communication

7. Drug and alcohol abuse

8. Domestic violence and sexual abuse

9. Extramarital involvement (not just sexual affairs)

10. Gender (roles, expectations, and society)

11. Cultural factors (including mainstream)

12. Ethical dimension (therapist and family’s ethics)

O. Working with managed care - it’s necessary, so cooperate

IV. The Fundamental Concepts Of Family Therapy - Chapter 4 — Outline by Anabella Pavon

A. Conceptual influences on the evolution of family therapy

1. Opening thoughts

a. Systems theory

i. Consensus among family therapists about systems theory - most influential in development

ii. Consensus among family therapists about systems theory - don’t really know how to explain it

iii. Systems theory - abstract concept; way of thinking rather than established doctrine

b. Many influences on family therapy

i. Biology v. Community mental health

ii. Physiology vi. Anthropology

iii. Cybernetics vii. Social work

iv. Psychosomatic medicine

2. Functionalism

a. Reaction to evolutionary method of removing from context

b. Anthropology - Malinowski and Brown - need to study in context

c. Functionalist premise - "...the adaptive value of any activity can be found if the behavior is viewed in the context of the environment" (pg. 110)

d. Evolutionary theory and psychoanalysis

e. Bateson

f. Functionalist influence on family therapy

i. Deviant behaviors may be functional - (scapegoats)

ii. Brass tacks - families are organisms adapting to environment in context - problems with family show problems with adjustment to environment

iii. Problem - "us against them"

3. General systems theory - Bertalanffy - a misinterpretation

a. All systems are subsystems

b. What did family therapy forget? Larger systems

c. Is it important for family therapists to consider values?

4. Cybernetics of families

a. Weiner’s idea of self - correcting systems

b. Feedback loop

i. Negative feedback loop - reduces deviation or change

ii. Positive feedback loop - amplifies deviation or change

c. Cybernetics applications to families: family rules, neg. Feedback, sequences of interactions, positive feedback loops when neg. Feedback loops don’t work

d. Metacommunicating - communicating about communicating

e. Bateson - introduced concept to family therapy - movement from linear circular causality

f. Split - Haley control and power vs. Bateson

5. From cybernetics to structure

a. Haley - coalitions

b. Structural concept of families - subsystems with boundaries

c. Basic premise - chance structural context, change individual

d. Minuchin - cartographer of family structure

6. Satir’s humanizing effect - look at nurturance instead of control

7. Bowen and differentiation of self

a. Undifferentiated family ego mass

b. Differentiation of self

c. Multigenerational transmission process

8. Family life cycle - see pg. 124

B. Enduring concepts and methods

1. Interconnectedness

2. Sequences of interaction

a. Triangles

b. Circular sequences

c. Indirect communication

3. Family structure

4. Function of the symptom

5. Circumventing resistance

6. The nonpathological view of people

7. Family of origin

8. Focussing on solutions

9. Changing a family’s narrative

10. The influence of culture

V. Bowen Family Systems Therapy - Chapter 5 — Outline by Jared Warren

A. Sketches of leading figures

1. Murray Bowen

2. Philip Guerin

3. Thomas Fogarty

4. Betty Carter

5. Monica McGoldrick

6 Edwin Friedman

7. Michael Kerr

8. James Framo

B. Theoretical formulations

1. Differentiation of self

2. Triangles

3. Nuclear family emotional process

4. Family projection process

5. Multigenerational transmission process

6. Sibling position

7. Emotional cutoff

8. Societal emotional process

C. Normal family development

1. All families lie on continuum from emotional fusion to differentiation

2. Optimal family development: good differentiation, low anxiety, parents in good emotional contact with families of origin

3. Fogarty elaborates 12 characteristics of well - adjusted families in "systems concepts and the dimensions of self’ (1976)

4. Hallmark of well adjusted person is rational objectivity and individuality

5. Carter and mcgoldrick elaborated the family life cycle

a. Leaving home

b. Joining of families through marriage

c. Families with young children

d. Adolescence

e. Launching children and moving on

f. Families in later life

6. First - order change vs. Second - order change

D. Development of behavior disorders

1. Symptoms develop when level of anxiety exceeds system’s ability to cope

2. Most vulnerable individual is most likely to develop symptoms

3. Bowen’s primary approach: calm down the parents and coach them to deal more effectively with the problem

4. Guerin and fogarty put more emphasis on relationship with symptomatic child and nuclear family triangles

5. According to bowen, behavior disorders result from emotional fusion transmitted from one generation to the next

E. Goals of therapy

1. Keys to therapy: process and structure

2. Primary goals: decrease anxiety and increase differentiation of self

3. Creation of new triangle in therapy between husband, wife, and emotionally neutral therapist

4. Goals for extended family: developing one - to - one relationships and avoiding triangles

5. Approaches of Guerin and McGoldrick

F. Conditions for behavior change

1. Therapists must avoid taking sides and promoting triangulation, and avoid being reactive to inevitable emotionality in families

2. Change requires awareness of entire family

3. Development of personal relationship with everyone in family

G. Techniques

1. Bowenian therapy with couples

a. Use of displacement

b. Therapist concentrates on process of couple’s interactions

c. Use of the "i - position"

d. Didactic teaching

2. Bowenian therapy with one person

a. Goal of differentiation

b. Genograms

c. Identifying triangles, reentry into family of origin

H. Evaluating therapy theory and results

1. Major shortcoming: can neglect importance of working directly with nuclear family

2. Evaluation has relied more on clinical reports than empirical data

I. Summary - Seven prominent techniques

1. Genogram

2. The therapy triangle

3. Relationship experiments

4. Coaching

5. The "I-position"

6. Multiple family therapy

7. Displacement stories

VI. Experiential Family Therapy — Chapter 6 — Outline by Sarah Sifers

A. Leading figures and background

1. Emerged in the 1960s from humanistic psychology and drew heavily from gestalt therapy and encounter groups (it is not very popular today)

2. Carl Whitaker

3. Virginia Satir (yes, the same one from communications family therapy)

4. Walter Kempler

5. Bunny and Fred Duhl

6. David Kantor

7. Current figures: Leslie Greenberg and Susan Johnson

B. Theoretical formulations

1. Commitment to freedom, individuality, personal awareness, individuals’ goals and values, self - expression, and personal fulfillment, but largely atheoretical

2. There is a wide variety of perspectives that a rather loosely connected under the heading of experiential family therapy

C. Normal family development a. Continuous growth and change and flexibility b. Nurtures and supports individual growth and experience (which leads to increased growth in the family) open (say anything) and constructive problem solving c. Natural and spontaneous; freedom, privacy, and togetherness

D. Development of behavior disorders

1. Family and societal pressures prevent naturally occurring self - actualization

2. Denial of impulses and suppression of feelings (emotional deadness)

3. Seeking security and stability (rigid) rather than satisfaction

4. Loyalty to family stressed over loyalty to self

5. Mystification - smothering emotion and desire

6. Marriages consist of two people trying to work out conflicts that arise from each trying to reconstruct his or her family of origin and their differences frighten them causing them to cling closer together

7. Includes "normal" difficulties such as infidelity or "quiet desperation"and "invisible" (culturally accepted) symptoms such as overwork and smoking

8. Intrapsychic defenses that lead to interpersonal problems

9. Getting stuck during a life transition or change

10. Lack of warmth >>> avoidance >>> preoccupation with outside activities

11. "wrong" communication: blaming, placating, being irrelevant, and being super reasonable

E. Goals of therapy

1. Find fulfilling roles for self that don’t override concern for the needs of the family as a whole (personal growth and family integration)

2. Increased self - awareness and expression that facilitates open family communication (you can’t communicate what you’re not aware of)

3. Growth, personal integrity, freedom of choice, less dependence, "expanded experience," increased sense of competence, self - esteem, and well - being

4. Openly acknowledge support, and make use of individual differences

5. Being spontaneous, "crazy"

F. Conditions for behavior change

1. Evocative measures (resulting in anger, anxiety, etc.) To create therapeutic change by opening people up or discover hidden emotions

2. Therapist must be warm and supportive, become a family member, be a "real person"

3. Therapist teaches by example how to be open, honest, and spontaneous

4. Including as many family members as possible (3 generations and kids)

5. Therapist needs to be mature, experienced, and have a satisfying family life

G. techniques

1. Clarifying communication (often through directives)

2. Focus on solutions rather than past grievances and point out positives

3. Support all family members’ self - esteem

4. Asking questions about emotions that are not expressed clearly (ind. Nonverbal cues)

5. Use of touch

6. Use of co - therapists to manage counter - transference

7. Very little formal assessment or history taking

8. Specific techniques (see book for description): family sculpture, family puppet interviews, family art therapy, conjoint family drawings, gestalt therapy techniques, symbolic drawing of family life space, role playing, there - and then techniques, "psychotherapy of the absurd"

9. Interrupting family dialogues to work with individuals

H. Evaluation

1. No empirical studies, but some anecdotal support

2. Family therapists would benefit from being more honest and open with clients

3. Shifting the focus to an individual is a way to stop family bickering


VII. Psychoanalytic Family Therapy - Chapter 7 — Outline by Anabella Pavon

A. Introduction

1. Many early family therapists have their roots in psychoanalytic training

2. Several psychodynamic therapists completely turned away from looking at the individual

3. 80s - family therapists looked at the individual again

4. Paradox: psychoanalysis is for the individual, family therapy the family. How can there be Psychoanalytic family therapy?

B. Sketches of leading figures

1. Four groups of contributors to psychoanalytic family therapy - forerunners, psychoanalytically trained pioneers, psychoanalytic ideas and thoughts when the field turned from psychoanalytic ideas, and contemporary psychoanalytic family therapists

2. Adelaide Johnson - superego lacunae - gaps in personal morality passes on by parents

3. Erik Erikson - sociology and ego psychology

4. Wait ... There’s more - Erich Fromm predecessor of Bowen, Sullivan, Wynne, Lidz, Acherman - strongest tie to psychoanalytic theory

5. Nathan Acherman - the psychodynamics of family life (1958) - first book dealing strictly with diagnosis and treatment of families

6. Ivan Boszormenyi - Nagy - center of family therapy at the eastern Pennsylvania Psychiatric Institute.

7. Dicks - worked with couples in England

8. John Bowlby

C. Theoretical formulations

1. "Practical essence of psychoanalytic theory is being able to recognized and interpret

Unconscious impulses and defenses against them ....

2. Freudian drive psychology - sexual and aggression

3. Self psychology - people want to be appreciated

4. Object relations theory - bridge between psychoanalysis and family therapy - relate to people in the present partially based on expectations we develop in early relationships

D. Normal family development

1. Healthy psychological development based on good early environment - parents - good object relations

2. Lots of talk about the mother and early mother/child attachment

3. Separation/individuation - provision of reliable support from mother is necessary

4. Parents need to be empathetic and model idealization

5. Ivan Boszormenyi - Nagy - contextual therapy - concerned with the ethics of families "loyalty and trust provide the glue that holds families together"

E. Development of behavior disorders

1. Where non - psychoanalytic family therapist look at problems in interactions between people while psychoanalytic therapists look at problems in the actual people in the


2. Symptoms come from attempting to cope with unconscious conflicts and the Anxiety that signals the emergence of repressed impulses"

3. Some problems can occur with parents not accepting children’s separation

4. Kohut - mirroring and idealization - when these needs aren’t met from parents, go on to be showy and seek admiration

5. Fixation and regression in families - after marriage, people can go back to behaviors seen when they were younger

6. Nnagy - symptoms occur when trust breaks down in relationships - individuals feel the effects

7. Kernberg - blurred boundaries occur when connections are formed with family members

F. Goals of therapy

1. " . . . Free family members of unconscious restrictions so that they’ll be able to interact with one another as whole, healthy persons on the basis of current realities rather than Unconscious images of the past."

2. Therapy focuses on supporting defenses and helping communication instead of analysis of defenses and finding repressed needs and impulses

G. Conditions for behavior change

1. Insight is necessary - in family therapy expand that insight knowing that psychological life goes beyond conscious experiences. Want family members to understand and accept repressed parts of personalities. Need to work through those things.

2. Important for the therapist to establish a sense of security

H. Techniques

1. Four basic techniques - listening, empathy, interpretation, and keep analytic neutrality

2. Don’t focus on reassuring or advise or confronting, silence is important. If they do intervene it’s to provide empathic understanding to help member of the family open up. Analysts also clarify things that appear to be hidden or need clarification

3. Mostly used with couples.

4. Therapists focus on the feelings associated with problems, not the causality to begin questioning about what’s at the root of the problem

5. Explore in four areas with couples: internal experience, history of the experience, how partner can trigger the experience, and how the context of session and therapist’s input might contribute to the situation

6. "Family dynamics are more than the additive sum of individual dynamics" (p. 228)

7. Therapist has to have a hypothesis

VIII. Structure Family Therapy — Chapter 8 — Outline by Patty Salehpur

A. Assumptions

1. Family are individuals who effect each other in powerful but unpredicatable ways

2. The consistent repetitive organized and predictable patterns of family behavior are important

3. The emotional boundaries and coalitions are important

B. Salvador Minuchin

1. Always concerned with social issues

2. Developed a theory of family structure and guidelines to organize therapeutic techniques

3. 1970 headed Philadelphia Child Guidance Clinic where family therapists have been trained in structural family therapy ever since

4. Born in Argentina , served in the Israel army as a physician, in the USA trained in child psychiatry and psychoanalysis with Nathan Ackerman, worked in Israel with displaced children, also worked in the USA with Don Jackson with middle class families.

5. Fist generation of family structural therapists: Braulio Montalvo, Jay Haley, Bernie Rosman, Harry Aponte, Carter Umbarger, Marianne Fishman, Cloe Madanes, and Stephen Greenstein.

C. Theoretical formulations - three essential constructs

1. Structure — the organized pattern in which family members interact, predictable sequences of family interaction, patterns of interaction. Structure involves a series of covert rules. There are universal and idiosyncratic constraints. Families may not be able to tell you the family structure, but they will show it to you in their interactions.

2. Subsystems — Families are differentiated into subsystems of members who join together to perform various functions. Each person is a member of one or more subsystems in the family. Some groupings are obvious and based on such factors as generation, gender, age or common interests. Other coalitions may be subtle. Every member may play many roles in various subgroups.

3. Boundaries are invisible barriers that regulate the amount and nature of contact with members. They range from rigid to diffuse, clear to unclear, disengaged to enmeshed

D. Normal family development

1. Marriage begins with accommodation and boundary making

2. Couples are influenced by the structure of their families of origin

3. Couples also form boundaries with their families of origin

4. The advent of children requires that the structure of the family change

E. The development of behavior disorders

1. Family dysfunction results from stress and failure to realign the structure to cope with it.

2. Disengaged families have rigid boundaries and excessive emotional distance. They fail to mobilize to deal with the stress.

3. Enmeshed families have diffuse boundaries and family members overreact emotionally and become intrusively involved with one another. These actions hinder mature actions to resolve stress.

4. Subsystems in the family may be disengaged or enmeshed.

5. Power hierarchies may develop which may be weak and ineffective or rigid and arbitrary.

6. Conflict avoidance prevents effective problem solving.

7. Generational coalitions may also prevent effective problem solving.

8. Family structure may fail to adjust to family developmental processes.

9. A major change in family composition demands structural adaptation.

10. Symptoms in one family member may reflect dysfunctional structural relationships or simply individual problems.

F. Goals of therapy

1. Changing family structure - altering boundaries and realigning subsystems

2. Symptomatic change - growth of the individual while preserving the mutual support of the family

3. Short-range goals may be developed to alleviate symptoms especially in life threatening disorders such as anorexia nervosa, but for long-lasting effective functioning the structure must change. Behavioral techniques fit into these short-term strategies.

G. Techniques — join, map, transform structure

1. Joining and accommodating, then taking a position of leadership

a. Listen to "I" statements

2. Enactment for understanding and change

3. Working with interaction and mapping the underlying structure

a. Looking at the power hierarchies

b. Using enactment to understand and clarify

c. Looking at the boundary structures

4. Diagnosing

a. individual vs. subgroup

b. structural diagnosis

5. Highlighting and modifying interpersonal interactions is essential

a. Control intensity by the regulation of affect, repetition and duration

b. Don’t dilute the intensity through overqualifying, apologizing or rambling

c. Shape competence, e.g. "It’s too noisy in here. Would you quiet the kids."

6. Boundary making and boundary strengthening

a. Seating

b. Seeing subgroups or individuals to foster boundaries and indivduation

c. Clarify circular causation

7. Unbalancing may be necessary

a. Taking sides

b. Challenging

c. Directives

8. Challenging the family’s assumptions may be necessary

a. Teaching may be necessary

b. Pragmatic fictions

c. Paradoxes

d. Therapist sometimes must challenge the way family members perceive reality, changing the way family member relate to each other offers alternative views of reality.

9. Therapists must create techniques to fit each unique family

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