Systems Theory and Family Therapy

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Homeostasis

Concept of homeostasis was one of the first concepts that guided family therapy
The idea that families tend to resist change in order to maintain a steady state.
Balance is maintained through homeostasis.
Other approaches may call this "resistance"
Family therapists believe this is what keeps individuals and families stuck in cycles and/or behaviors
-Someone always needs to maintain one of the roles to keep Homeostasis going

Process vs. Content

Two different areas of focus
Content: what is being said
What the argument is about (eg., curfew)
Process: the deeper meaning, message, and interactions used
How the family argues?
What messages are sent?
Mom withdraws, Dad lectures, Kid is aggressive
The temptation is to get caught up in the content!!

Role Theory

What roles are family members expected to play?
Very difficult for family members to stop playing these roles
-The perfect child
-The rebel
-The athlete
Others??
Roles may become reinforcing:
The good child is always good and the bad is always bad because neither gets the opportunity to be the other

Child Guidance Emphasis

Kids were historically treated individually ... families were viewed as an extension of children
Mothers were sometimes seen separately from their children but the social workers/psychiatrists did not collaborate
Parents were frequently blamed (esp. mothers)
Term: schizophrenogenic mother- Thought that mothers cause schizophrenia- 1950s
Bowlby worked some with families.. But Nathan Ackerman was the one to take the lead

The Palo Alto Group

Gregory Bateson/Schizophrenia Research
Don Jackson & Jay Haley
Focus on communication
Meta-communication
2 levels of communication/messages
Report and Command
Meta-communication is the implied command
E. g.,: clean your room (message is "you never do anything right and I have to remind you of everything")- layered communication; listen on multiple levels
Or: I thought you were going to call when you got off work.

Double Bind (Palo Alto Group)

First identification of the family's influence on behavior
observed initially in schizophrenic individuals
This idea of "do this but don't do this"
Contradictory messages within an intimate relationship that lead to conflict
Example: mom stiffens when son gives a hug, son withdraws, mom says "don't you love me?", son embarrassed, mom criticizes son's feelings
-Wife that says "please do the dishes, then says why aren't you spending time with me?"

Don Jackson

Identified family homeostasis

Complementary relationships

Don Jackson
Partners are different but they fit (like a puzzle)
Logical, emotional
Weak, strong

Symmetrical relationships

Don Jackson
Based on symmetry and equality
eg: both work, share chores, etc.

Family rules

Don Jackson
Idea that families follow the underlying rules - and only use a small range of behaviors

Identified that family patterns maintain symptoms
-Functional vs. Problematic
-Asking the family what secondary gains would be
-Secondary Gain: Dealing with the root problem

Scapegoat
-May be the "identified patient"- the one that "brings" the family into counseling
-Idea that families take out symptoms on one individual
-Frequently the child (can also be viewed as the symptom carrier)

Jay Haley

Family communication
-Different levels of communication at the same time
Go clean your room ... what does it really mean?
Directive therapy
-Telling people to do what they fear

Virginia Satir

First family therapist to really look at emotion
Focus on communication and emotion
Conceptualized families as stuck in narrow roles
Goal was to free family members from these roles

Theodore Lidz

Did not believe that mothers caused schizophrenia
Identified 2 types of marriages - both leave kids feeling responsible to balance the marriage

Psuedomutuality

Lyman Wynne
"a façade of togetherness that masks conflict and blocks intimacy"
No room for uniqueness or separateness
Avoidance of deep, intimate relationships

Psuedohostility

Lyman Wynne
Arguing and bickering that hides "pathological alignments" in families
Appears to be separateness but that is a façade
Prevents open communication and quality relationships

Marital Skew

Theodore Lidz
-One parent is a "pathologic bully" and the other is passive/dependent; think military father
-Example: Self-centered father appearing as dominant but is actually very bullying

Marital Schism

Theodore Lidz
-Husband and wife undercut each other's worth and/or compete openly for attention/affection of the children
Example: Devon (presented as a child problem)- parents fought over who took the best care of their child

"Rubber Fence"

Lyman Wynne
Observed in these families
Keep outsiders out, and insiders in... with the appearance of being open
These families became "sick little societies"
May present as seeking help... but not let clinician in

Murray Bowen

Father of the genogram
Initially specialized in schizophrenia - Menninger Clinic
Heavy emphasis on theory, less emphasis on intervention

Differentiation of self
-Independence from others - emotionally, cognitively, etc.

Triangles
-Bringing in a 3rd person to relieve tension (Amanda's example of her friends Sara and Kristi)

Emotional reactivity of families
-Inability to think clearly because of emotion
Families will pull therapists into this emotion

Nathan Ackerman

Forerunner in promoting family therapy

Unique in that he focused both on family relationships and individual considerations

Therapy including provoking families to address issues commonly avoided (such as sex and aggression)- usually danced around in family therapy

"He never lost sight of the self in the system."

Salvador Minuchin

Identified 2 patterns in families
Both patterns lack clear authority

Enmeshment
Parents over-involved; no hierarchy or line between parent and child

Disengagement
Parents not involved

First order change

Minuchin
Superficial change
Eg: I bought you flowers because I hurt your feelings

Second order change

Minuchin
A change in the system itself
More lasting and concrete
Eg: I stopped berating you in public because I understand how it impacts you

Carl Whitaker

Referred to as "irreverent"
"turned up the emotional temperature" in therapy

Ivan Boszormenyi-Nagy

Psycho-analytical roots
Father was an accountant
Contextual therapy

Cybernetics

The tendency of families to maintain stability

Feedback loop
How a family gets information to maintain stability - steers the family towards homeostasis
-Example: husband takes out the trash, wife nags, etc.; it is an interaction that repeats itself every week

Negative feedback
Return to stability or normal - no new information
Status quo within the family- maybe the husband doesn't get angry and instead ignores the wife, but still takes out the trash.

Positive feedback
Attempt to change - only means new information, not necessarily good/positive
2 outcomes: former homeostasis OR new homeostasis
Common response: getting back to normal
Death, fighting, graduation, re-marriage

Cybernetics

Focus on the following:
Homeostasis
Family rules
Negative feedback
Positive feedback
Sequences of family interaction

See the model in the first day power point that models the cycle

Attachment Theory

Developed by John Bowlby
Based on the concept that we have an innate need for others

We seek closeness of others when we are stressed

Definition:
Biological, psychological, & social connections between a child and caregiver(s)

"Will you be there for me?" "Can I depend on you when I need you?"

How the caregiver(s) responds to these questions sets the stage for attachment.

Smiles, eye contact, touch, holding, positive affect, rocking, etc.

Working Concepts

People are products of their context - specifically the family but can be applicable in other contexts

There is complementarity in relationships: behaviors are linked together, patterns occur, we are influenced by others

Linear causality versus circular causality - Linear looks at finding a root of a behavior versus a repeating cycle
Cause and effect versus cycles

Process versus content
How people talk versus what they talk about

Triangles
Means to alleviate anxiety

Working Concepts Continued...

Family Structure
-The organization of the family
Subsystems (THIS IS WHAT WE REALLY WANT TO KNOW ABOUT)
-Parents
-Kids
-Athletes
-Other ideas?

Boundaries- "I talk to Mom about this and Dad about this"
-Lines within families that explain how to communicate, act, express emotion
-Disengaged
-Enmeshed

Leaving home: single young adults

Accepting emotional & financial responsibility for self
Changes Required:
Differentiation of self
Develop intimate relationships
Establish self in work & financial independence

Marriage: the new couple

Commitment to new system

Changes Required:
Formulation of marital system
Realignment of relationships with extended family and peer group

Families with young children

Accepting new members into system

Changes Required:
Adjusting marriage to make space for kids
Joining in new tasks
Change in relationships: parenting and grandparenting

Families with teens

Increasing flexibility of boundaries to enhance children's independence and grandparents needs

Changes Required:
Shifting of relationships to allow teen to move in/out of system
Refocus on midlife marital and career issues
Caring for grandparents

Launching children and moving on

Accepting numerous exits and entries into system

Changes Required:
Renegotiation of marriage
Renegotiation of parent/child relationship
Including in-laws and grandchildren
Dealing with grandparents

Families in later life

Accepting the shifting generational roles

Changes Required:
Maintaining marriage
Focus on middle generation
Supporting older generation
Dealing with loss

Types of Genograms

Can do genograms to focus on
Mental health
Spirituality
Messages
Physical health
Relationships

Genogram as intervention
Increase awareness
Finding patterns
Psycho-education

Resilience: Froma Walsh

3 major areas of resilience
Belief Systems
Organizational Patterns
Communication and Problem Solving

Goals of the resilience perspective
Decrease family risk factors
Reduce negative chain reactions that heighten risk for sustained impact and further crisis
Strengthen protective family processes and reduce vulnerabilities
Bolster family and individual pride through successful problem mastery

-Families that don't have resilience usually get stuck in the system.

#1 Belief Systems (Resilience)

How the family views a crisis, suffering, or options

Making Meaning of Adversity
Families view it as a family problem vs. individual problem
Normalizing stress vs. being victimized (believing that bad stuff will happen; how are we going to make sense of it) (Resilience comes from accepting that we live West of Eden)
Coherence: work together, look at context

Positive Outlook
Sense of hope, learned optimism
Helps to encourage families strengths during a crisis
Accept what can't be changed

Transcendence and Spirituality
-Connection with something larger- making sense of the nonsensical
-Faith community
-Inspiration

Paradox of Resilience
-The worst of times can also bring out the best

#2 Family Organizational Patterns (Resilience)

How the family organizes to meet challenges

Flexibility (Metaphor of a tree; the branches can move and sway and still stay rooted)
-Openness to change
-Stability through disruption
-Strong authoritative leadership (provides the stability)
--Nurturing, protecting, guiding
--Cooperative co-parenting, equality in parental subsystem

#3 Communication and Problem Solving (Resilience)

Clarity in a crisis, emotional expression

Clarity
Clear and consistent messages (verbal and nonverbal)
Clarify ambiguity - speak the truth (say what you mean, do what you mean)

Open Emotional Expression
Emotions are accepted
Empathy, humor
Responsibility for personal emotions
Little blaming

Collaborative Problem Solving
Brainstorming (coming up with a plan to attack/defend against the system)(example of prof's grandmother preparing to die and the family talking about it)
-Shared decision making, negotiation, fairness
-Conflict resolution
-Create a concrete plan to solve the problem
-Prevention of problems

McCubbin's Family Stress Model

Developed by husband and wife
Found resiliency factors that help a family maintain resilience in the presence of stressful events

McCubbin: Ten general resiliency factors - both protective and recovery

1. Family problem solving and communication
2. Equality
3. Spirituality
4. Flexibility
5. Truthfulness (truth from family as well as agencies, doctors, etc.)
6. Hope (can things be better in the future?)
7. Family Hardiness
8. Family time and routines
9. Social support
10. Health

Froma Walsh: Practical Principles

"No single thread distinguishes well-functioning from dysfunctional families, as pioneering studies have found."

"When clinical formulations reduce the richness of family interactions to simplistic labels such as 'an enmeshed family', an alcoholic family', 'a codependent family', they both stereotype and pathologize families." -systemic therapy steers away from labeling people; labels keep us from seeing people as complex

"Instead, mental health professionals must attend to the many strands that are intertwined in family functioning, and need to assess strengths and vulnerabilities on multiple system dimensions.

Good way to think about systems

one of those planets projects from elementary school. you can pull down Jupiter and work with it, but if you don't change the whole system, Jupiter is going to have a hard time staying changed, unless it intentionally affects change

Systemic Assessment

Can occur with individuals, couples, or families

Does not focus solely on individuals- there's always a bigger story going on

Focus on relationships- dynamics that affect each person

Considers dynamics
-within the family
-Relationships
-Interactions
-outside of the family
-Church, Extended Family, Neighborhood, School, etc.

How do these dynamics impact:
Individuals within the family
The family as a whole

More Systemic Assessment

Multidimensional
Contextual (are they coming to you in the midst of a tragedy, etc.)
Process/content
Sequential/priority (What is top priority? example: getting a daughter to come out of her room)
Responsive to family needs

Two major questions of each theory

Family Processes
What are the explicit and implicit assumptions about normal - typical and optimal - family functioning and views of dysfunction?

Therapeutic Goals and Change Processes
How do these beliefs influence therapeutic goals and objectives and intervention processes?

Systemic Assessment Application

Family Processes
What are the explicit and implicit assumptions about normal - typical and optimal - family functioning and views of dysfunction?
What do you consider to be "normal" family functioning?
What are signs of health in families?
What do you consider to be "dysfunctional" family functioning?
What are red flags or signs of struggle?

Systemic Assessment Cont...

Research is showing the multiple family configurations can be functional...

It is less about the actual formation of the family

MAIN POINT: The functionality of the family is more about communication, family processes, and relationship quality.

Do not be quick to assume that the form of a family is an indicator of its functioning (like don't assume a family with step-children/parents is going to be bad)

Assessing for family's view of functioning

How do members view their own family as a system and each individual?
How do they believe others view the family?
How do they believe others view the individuals within the family?
How do they compare their family to other families?
How do they compare their family to overall society's views on families?

Holistic assessment:

Obtain perspective of each family member

Who is identified as a family member?
Not always a "blood" relative
Explain that family does not have to mean "household"
Examples: nanny, coach, college student

Genogram can be a good assessment tool

Family time lines can help identify important events and/or symptom presentation

Include previous family subsystems (divorce, dating, remarriage)
Anticipated future changes
Especially consider changes in the family household

Areas to consider in your assessment:

Belief systems of the family
-Shared or different- does everyone share that belief system?
-Not just spiritual beliefs
-Beliefs of change
-Beliefs of ability to handle crises
-Beliefs of strengths of the family and/or individuals
-Family themes
Achievement
Money
Status
Athleticism
Legacy

Areas to consider in your assessment:

Organization Patterns of the family
Flexibility
Is the family dependable?
How does it respond to change?
Rigid interactions?

Connectedness between members (health is usually a midway point between enmeshed and disengaged)
Boundaries
Trust, respect
Leadership
forgiveness

Social and economic resources (job changes can change the family system)
Extended family
Community networks

Areas to consider in your assessment:

Communication Processes of the family
Clarity of communication
Messages are not ambiguous
Expectations are clear

Open emotional expression
Emotional reciprocity
Individuals allowed to have emotions that differ from others

Collaborative problem solving
Shared decision making; brainstorming
Prevention of problems
Conflict resolution

Global Assessment of Relational Functioning

Relational guide to levels of functioning
Global Assessment of Relational Functioning (GARF)
Added to the DSM-IV in 1994
Rate the degree to which a family or other ongoing relational unit meets the affective or instrumental needs of its members in the following areas:

Global Assessment of Relational Functioning: 3 areas of assessment

Problem solving: skills in negotiating goals, rules and routines; adaptability to stress; communication skills; ability to resolve conflict

Organization: Maintenance of interpersonal roles and subsytem boundaries, hierarchical functioning, coalitions and distribution of power,control and responsibility

Emotional Climate: tone and range of feelings; quality of caring, empathy, involvement, and attachment/commitment, sharing of values; mutual affective responsiveness, respect, and regard; quality of sexual functioning

Global Assessment of Relational Functioning: Rating Scale

81-100 Relational unit is functioning satisfactorily from self report of participants and reports of observers
61-80 functioning of relational unit is somewhat unsatisfactory. Over a period of time, many but not all difficulties are resolved without complaints
41-60 Relational unit has occasional times of satisfying and competent functioning together, but clearly dysfunctional, unsatisfying relationships tend to predominate

Global Assessment of Relational Functioning: Rating Scale

21-40 Relational unit is obviously and seriously dysfunctional; forms and time periods of relating are rare
1-20 Relational unit has become too dysfunctional to retain continuity of contact and attachment

Circumplex Model

David Olson - stems from his research on families and pre-marital couples
Assesses both couple relationship and family of origin
Two Axes:
Flexibility
Closeness

Circumplex Model

Hypotheses of the model
Balanced couples and families will generally function more adequately across the family life cycle than unbalanced types.
Not functioning in extremes of either flexibility or closeness
If a couple's/family's expectations or subcultural group norms support more extreme patterns, families can function well as long as all family members desire the family to function in that manner.

Circumplex Model

Hypotheses of the model
Positive communication skills will enable balanced types of couples/families to change their levels of cohesion and flexibility.
Poor communication prevents movement in families
Couples/families will modify their levels of cohesion and/or flexibility to deal effectively with situational stress and developmental changes across the family life cycle.

Circumplex Model: Closeness

"Balanced couples and families tend to be able to balance their separateness (I) versus their togetherness (We)."
Couple and family closeness is measured by:
Separateness/togetherness
Closeness
Loyalty
Independence/dependence

Circumplex Model: Closeness

Unbalanced: Disconnected
- too much (I) separateness
- little closeness
- lack of loyalty
- high independence
Balanced: Somewhat Connected to Very Connected
- good I-We balance
- moderate to high closeness
- moderate to high loyalty
- interdependent
Unbalanced: Overly Connected
- too much (We) togetherness
- too much closeness
- loyalty demanded
- high dependency

Couple Closeness (Circumplex Model: Closeness)

We really like to do things with each other.
We ask each other for help.
We spend too much time with our friends or relatives.
We share hobbies and interests.
Jealousy is an issue in our relationship.
My partner & I really enjoy spending our free time together.
We feel very close to each other.
We find it easy to think of things to do together.
We consult each other on all important decisions.
Our togetherness is a top priority for us.

Family Closeness (Circumplex Model: Closeness)

Family members ask each other for help.
Family members approve of friends.
Our family likes to do things with each other.
Family members enjoy being together.
Our family likes to spend free time together.
Family members feel close to one another.
When our family gets together for activities, everyone is present.
It is easy for us to think of things to do together.
Family members consult on decisions.
Family togetherness is very important to our family.

Circumplex Model: Flexibility

"Balanced couples and families tend to be able to balance their stability versus change."
Couple and family flexibility is measured by:
- stability versus change
- leadership
- roles
- discipline

Circumplex Model: Flexibility

Unbalanced: Overly Flexible
- too much change
- lack of leadership
- dramatic role shifts
- erratic discipline
Balanced: Somewhat Flexible to Very Flexible
- can change when necessary
- shared leadership
- role sharing
- democratic discipline
Unbalanced: Inflexible
- too little change
- authoritarian leadership
- roles seldom changed
- strict discipline

Circumplex Model: Flexibility
Couple Flexibility

We compromise when problems arise.
We are creative in how we handle our differences.
In our relationship, we share leadership equally.
Both of us are able to adjust to change when it's necessary.
We try new ways of dealing with problems.
We make most decisions jointly.
We seldom seem to get organized.
We will share household responsibilities equally.
We have difficulty completing tasks or projects.
We are flexible in our lifestyle.

Circumplex Model: Flexibility
Family Flexibility

Family members compromise when problems arise.
Our family is flexible in how discipline is handled.
When there are problems, our family becomes disorganized.
Things never seem to get done in our family.
Our family is able to adjust to change when necessary.
Parents and kids make decisions together in our family.
Our family has a hard time finding good ways to solve problems.
Our family shifts household responsibility from person to person.
We never seem to get organized in our family.
Our family has a rule for every situation.

Circumplex Model
Examples

For further information...
Prepare-Enrich Online
Chapter 19 Walsh text
Article on Angel

Basic Techniques of Family Therapy

Case Conceptualization
Life Cycle
Interaction Patterns
Cultural Factors (even the culture of the family)
Ethical Concerns (family secrets) (How am I ethically obligated to handle certain information?)

Assessments

Genogram
Earlier lecture
Begins with first phone call (who's making the phone call?)
Who comes to session?
Who talks more?
Verbal and nonverbal communication
Process vs content

Joining

-the process of connecting with those in your office in a way that gives you permission to call them on things.

Make an attempt to connect with each individual on some level
Your goal is to establish a safe environment for the family and the individuals
Part of this is your empathy, therapeutic stance
Another part is your curiosity
Getting the perspective of each family member

Curiosity

What is bringing this family in at this specific time?

Assess for interaction patterns (circular vs. linear)

Listen for process vs. content

Very important to get each person's perspective

How are other systems impacting the family?

What is family structure like?

First session checklist

Listen to each family member's point of view- don't let one person talk the whole time
Establish leadership - pacing and control; you have to be the one in charge
Working alliance
Identify resilience and strengths
Empathy
Identify problems and solutions
Develop hypotheses- you're always working on a hypothesis
Assess for extended family or other members
Explain Treatment- "They're may be times when I just work with your daughter, but sometimes I'll want to see you as parents."
Ask for questions

Early Phase Checklist

Identify major conflicts and identify them
Treatment plan
Balance focus on problem, interpersonal relationships
Homework
Identify family roles
Push for change in session and out of session

Middle-phase checklist

Increase intensity in session (balance with empathy)
Balance of direct and indirect communication with family
Increase individual responsibility within system
Strengthen family bonds
Assess therapist role
Maintain systemic perspective (be ready to watch someone revolt at the attempt of changing the system)

End-phase checklist

Is presenting problem improving/decreasing?
Is family happy/satisfied with treatment?
Family able to articulate progress?
How is family handling current stressors?
Are relationships within and without family system strengthened?
Predict future problems.

Transgenerational Therapy

Murray Bowen
Can be used with couples, families, and/or individuals

This theory is heavy on theory rather than intervention ... and is frequently intertwined with other models

Differentiation of self
Triangulation
Multigenerational Transmission Process
Emotional Cutoff
Nuclear Family Emotional System
Family Projection Process
Sibling Position
Societal Emotional Process

Differentiation of Self

main definition: the ability to experience difference
the self in relation to, but separate from, others
The ability to distinguish one's own thoughts and feelings as separate from others
within the marital relationship, differentiation includes outside relationship with others but also a solid relationship with the spouse
"In order to have resilience, partners have to possess a strong sense of personal identity that is not threatened by change." (p124)

Differentiation is the cornerstone for healthy long-term commitments
Individual differentiation influences the choice of the spouse
A healthy marriage includes two individuals who are able to have a caring connection with FOO
Bowen asserts that each individual brings his/her family of origin into the marriage

Triangulation (Bowenian)

Couples (or a family dyad) bring in a third party to relieve the anxiety within the dyad
Concept: couple as two poles, back and forth, when becomes unstable, bring in a third party for balance and stability
This third party becomes the boundary keeper (or peace keeper)
Most common third party is a child
Other triangles: affair, in-law, therapist, co-worker
Examples: mom-child dyad, dad in peripheral
wife-husband dyad, mom-in-law in peripheral
mother-child dyad, sibling in peripheral
Often a source for affairs

Triangulation Continued...

Secondary triangles: when 2 or more individuals ally as one corner of a triangle temporarily, on perhaps 1 issue only.
Example: initial triangle of mom, dad, and son; MGM sides with mom and son on an issue, creating a secondary triangle
The third person in the triangle is frequently pushing for change
Example: child is acting out at school because of triangulation with mom-dad dyad
Class discussion: Examples of triangles? Either in personal life or in media

Multigenerational Transmission Process (Bowenian)

The concept that levels of differentiation are taught (implicitly and explicitly) to younger generations of family members
As a result, family members become less and less differentiated as time goes on
Example: If a married couple focuses on one of their children excessively, this child will marry a similar individual with low differentiation. They will transmit this to their child, and the pattern will continue among generations.
Bowen saw this with the schizophrenic families he was working with
Low differentiation within a family system can lead to marital distress, dysfunction in a spouse, or dysfunction with a child

Emotional Cutoff (Bowenian)

May occur by moving away, isolation, or emotional avoidance
This can stem from being emotionally fused in relationships
Function of distancing is to maintain homeostasis or equilibrium
Common for fusion and cutoff to both exist in the same extended family
This is a "flight from an unresolved emotional attachment" per Bowen
Emotional cutoff can be either physical or emotional
It takes 2 people to maintain the cutoff

Emotional Cutoff Continued... (Bowenian)

Cutoff can be considered as a continuum
The mild form is part of differentiation
Establishing distance in order to create differentiated self
The extreme is cutoff
The mid form is "tearing away" in order to create a psuedo self (The teenager raised in the church that becomes an atheist)
This is different from "growing away"

Examples of the process of cutoff:

Not communicating due to distance
Avoiding communicating bad news
Increased conflict prior to separation (launching)
Being different from parent in order to increase emotional distance
Choosing not to acknowledge birthdays, anniversaries, or family events
No eye contact or verbal communication
Not using individual's name
Not initiating contact (but responding to it)
Not initiating contact or responding to it

Nuclear Family Emotional System

4 basic relationship patterns that can lead to problems within the family system
Present in multiple family structures (not just the nuclear family)
Family tension arises when external or internal stressors occur: tension appears in the form of anxiety within one of the patterns below:
Marital conflict
Dysfunction in one spouse
Impairment of one or more children
Emotional distance (fusion - little overt conflict)

The anxiety within one of these four relationship subcategories may be what brings the family or marital dyad into therapy
Consider... where does the anxiety present within this family?
Case examples:
Danny (22yo male from a successful family)
Luke (18yo male at USN)
The perfect family you may never see!

Family Projection Process

Parents transmit/project anxiety onto one of the children
Parents present with a calm marriage; over-concerned and concentrated on child (symptom carrier)
Family may bring child in for therapy when marital therapy is actually needed
Experiential: Brainstorm on ways you may assess for this and then bring it up to the parents

Sibling Position

A concept not as commonly considered
Bowen believed that sibling position within FOO played out in marital relationship
Also contributed to family projection process: the child with anxiety projected onto them was oftentimes infantilized

Societal Emotional Process

Society's impact on family emotional processes
Consider current economical, political, cultural, and societal issues that may be impacting the couple or family
Example: A Bowen Couples Therapist would consider the influence on a recent school scandal and how it may be impacting the parent's anxiety about a child

Assessment (Bowenian)

Specific interventions not clearly articulated; this approach is heavy on theory
Remember that changes within the family system will radiate out to extended family of origin
Assessment occurs within first 1-3 meetings, Genogram will be major tool used for assessment

Assessment:Genogram

Genogram will include 3 generations
Used to point out patterns, current problems, problem history: mainly focusing on multigenerational patterns
Patterns may include mental health, physical health, work, spirituality/religion
Also looking for major/critical incidents, key figures in FOO, important events in FOO, and the history of the marriage (also think DATES or TIME LINES)
Have each individual give own perspective of presenting problem (including how FOO has responded to problem)

Genogram helps therapist think long-term regarding treatment goals
Therapist to be culturally aware when assuming health of FOO and system
Part of this awareness includes social class, religion, culture

The Clinical Interview (Bowenian)

-getting to know the individual and the family he/she comes from
Used to obtain each individual's view of problem
Therapist begins to develop FOO context/treatment frame as this will guide treatment
Each individual's view of the problem is important as it frames the emotional needs and problem definition - this is used to shape interventions
Important to obtain time frame of problems
Looking for distribution of power
Distribution of power can be observed in decision-making, financial issues, parenting
Include affective assessment: how does family relate? Is there physical touch? Look for nonverbal and verbal expression of emotion
Consider past needs/wishes that have been met or unmet and how they are currently impacting the family

The process question (Bowenian)

Goal is to slow the client down, decrease anxiety, and get the client to start thinking differently
Examples:
When your mom calls you and nags, how do you handle it?
What happens when your family is all together?
Is this a pattern in your dating relationships?

The I-position (Bowenian)

Rather than blaming or criticizing, the individual takes responsibility for his/her feelings and thoughts
Goal is to decrease blame and attack within relationships

Creating a TG Frame (Bowenian)

Creating a TG Frame by the use of a genogram as an intervention that encourages self-disclosure and vulnerability
Genogram allows families to learn more about and gain a new perspective of their own FOO and each other's FOO
Genogram helps create this TG frame as it puts an emphasis on FOO

Tracking the Presenting Problem

TG therapist is observing power distribution, decision-making, story-telling, naming of the problem
Structural characteristics of the family are observed: distance, fusion, disengagement, cutoff, conflict

Tracking Antecendents

TG therapist tracks problem while observing what event triggered the current problem
Consider antecedents within whole system as well as dyads and within each FOO
Tracking 3 generations of family - acknowledges another dimension of the experience and presenting problem
Helps clients get to the root of things: see how FOO had an impact on the current dilemma

Family of Origin Consult

TG therapist arranges the consult during the mid-phase of therapy
Helps family make the connection of problem to FOO
FOO meetings only occur once or twice due to financial/time constraints
2 hour segments over 2 consecutive days
Frequently increases anxiety so family needs to be prepared for this visit
One family of origin at a time
Spouse just observes and does not participate
Spouse invites own FOO to the experience
Siblings frequently do not attend (though they are asked)

Role of the Therapist

Build strong therapeutic alliance
Looking at things from inside the system and creating safety to explore topics
"Partiality replaces neutrality." Each individual knows the therapist is neutral
TG therapist is transparent: using self but remaining separate/differentiated.
Participant observer
Self-disclosure helps family understand that the therapist is real and has also experienced challenges
Disclosed material is resolved material so counter-transference does not occur

Role of the Therapist

Therapy occurs in stages/phases so therapist role changes
Therapist seen as coach throughout
In the beginning, more directive
Mid-phase, increased use of self as couples begin to look at key relational/FOO issues
Late-stage, less coaching/expert stance as couple begins to solve problems on their own

FOO Consults-Structure

Spouse being visited explains presenting problem within the marriage
FOO encouraged to ask questions and explain what they know (emphasis is on spouse and not on FOO)
Each consult is different, depending on emotional tone and communication of FOO
Some FOOs resistant to discuss whereas others jump right in
Consults often increase spouse's awareness of what he/she has brought to marriage
After a consult the spouse is frequently more self-focused and willing to look at his/her own contribution to current problem

Strategic Therapy

A broad category stemming from the communications model
MRI Brief Therapy
Haley & Madanes' Strategic
Milan Systemic
General concepts guide the theory, but interventions and therapist presentation may look different

Overview of Strategic Therapy

People are always communicating
You cannot NOT communicate!!
Process and content are always present
Consider the context of the communication
Family rules play a role
Rules maintain homeostasis
Circular Causality
Feedback loop always in motion
Main focus of this model (all 3)

Overview of Strategic Therapy Continued...

First order and second order change
Behavior change vs family rules change (or heart change)
Reframes
Making a different interpretation of the behavior
Eg: child seeking attention from parents rather than being an unruly child
Behaviors in families developed to maintain homeostasis:
Function of the system

Overall goal of therapy is to improve communication patterns
This can be done by identifying sequences OR by blocking the sequences

MRI Brief Therapy (Strategic Therapy)

Mental Research Institute
Started by Don Jackson
Virginia Satir
Jay Haley
John Weakland
Paul Watzlawick
Brief Therapy Project
Richard Fisch
Arthur Bodin
Jay Haley
John Weakland
Paul Watzlawick

Assessment (MRI Brief Therapy)

Define a resolvable complaint
Get a picture of the complaint - from each person involved
"If we had a video of this, what would I see?"
Identify attempted solutions that maintain the complaint
Helps develop conceptualization of interaction cycle
Understand the clients' language for describing the problem
Helps define interventions in the family's language

MRI Brief Therapy Continued...

Did not identify a clear picture of normality due to the broad variance in families
Goal: to eliminate problems
Focus on circularity in communication
Family may encounter a "problem" and how each member responds determines if it continues or not ... or if the family gets stuck in the pattern.
Failed attempts at problem solving maintain the "vicious cycle"
Role of therapist: one-down stance

Intervention (MRI Brief Therapy)

Introducing the treatment setup
Inquiring about & defining the problem
Estimating the behavior that is maintaining the problem
Setting goals for therapy
Selecting and making behavioral interventions
Termination

Reframe problems so family understands
Paradoxical interventions
-Symptom prescriptions: increase intensity of symptoms (or make more grandiose)
-Goals: for client to rebel or for family to get tired
-Example: act more angry as a family... family gets tired, thinks it's ridiculous, or finds alternative solutions; the mother knows her daughter is going to throw a fit in the grocery store and tells the child "is that all you got?"

Strategic Therapy: Haley and Madanes

Jay Haley
Worked with MRI, then studied with Minuchin, then developed his own model
More strategy and a sense of almost manipulation in his view of therapy
Cloe Madanes
worked at both MRI and Child Guidance (with Minuchin)
Considered to be one of the most creative therapists of our time

Assessment (Haley and Madanes)

Problem definition
From view of each involved
Structural arrangements within the family
Triangles and coalitions
What is the payoff for each member?
Is power obtained? Attention?

Strategic: Haley and Madanes

Identified a concept of normalcy within families. Goal was to create more functional boundaries and hierarchies.
Rules within parental hierarchy set the tone for the family (for example, the parents shut the door every night; or Summer wanting me to read to her during dinner)
Haley believed that problems frequently stemmed from "disturbed hierarchies" within families
Interventions were specific to the family ... and creativity was a heavy influence

Strategic: Haley and Madanes

Haley & Madanes believed that labeling the problem or telling the family what to do leads to resistance
Madanes: "If a problem can be solved without the family's knowing how or why, that is satisfactory."
Haley focused on the meaning of the problems, interactions, and behaviors.
Also focus on power distribution within the family

My note: Different from Bowen because the therapist does things without telling the client why; there is no psycho-education involved. All SYMPTOM focussed

Prescribing the symptom (Haley and Madanes)

Telling a client to do a problem behavior
Shifts the behavior from involuntary to voluntary
Two possible outcomes:
Does the behavior and proves it is voluntary
Gives up the behavior all together
Considers the interpersonal payoff of the behavior

Metaphor (Haley and Madanes)

Behaviors are frequently metaphors within the family
Relationships may also replicate others

Pretend Techniques (Haley and Madanes)

Have family to pretend to have the symptom together.
Eg: telling lies

Prescribing Ordeals (Haley and Madanes)

Suggesting family members to do something each time a behavior occurs
Eg: Insomniac has to clean or pay bills when can't sleep
Eg: page 112 book
Cloe Madanes on Couples Therapy- video clip

Milan Systemic Model (Strategic Therapy)

Italian Psychotherapists
Mara Selvini Palazzoli
Luigi Boscolo
Gianfranco Cecchin
Guiliana Prata
Focus started on eating disorders ... then led to the incorporation of the family
Included male-female co-therapists and observers
Therapists have an attitude of neutrality: rather than having preconceived notions of normal, ask questions that lead to families examining selves ... with the hope that families would reorganize themselves.

Assessment (Milan Systemic Model)

Therapist starts with a hypothesis
Confirmed or disconfirmed in 1st session
Based on "identified patient"
Assessment questions focus on family as a set of interconnected relationships
Goal: develop a systemic perspective of problem

Intervention (MIlan Systemic Model)

Presession- involves family and clinicians
Session
Intersession- therapists talk to the observing team
Intervention
Postsession

All in one session

Positive connotation (Milan Systemic Model)

Identify positive impact of behaviors - how it's protecting the family
Presented to family as a hypothesis ... including how behavior is protecting the family
Eg., thanking the child for being symptom carrier- a better way might be to thank the child for serving the role rather than carrying/performing the symptom

Family rituals (Milan Systemic Model)

May have family do a ritual that's different from symptoms (eg., quality time)
Thanking symptom carrier for having symptom

Invariant prescription (Milan Systemic Model)

Asking parents to have mysterious communication
Inform the kids that a secret exists
Continues until symptoms stop
-reestablishes the parental hierarchy; could really change a child that is bossing the parents.
-then the therapist could create a session with the child about what they think/fear the assignment is about

Circular Questioning (Milan Systemic Model)

Used to highlight differences among family members
Example page 114- shifting from the child being the problem to a circular interaction that looks at a bigger picture

Boundaries (Structural Therapy)

Rules for managing physical and psychological distance

Clear boundaries
Refer to a range of normal - a balancing of closeness and distance

Enmeshment and Diffuse Boundaries
-Overly involved leading to symptoms
Disengagement and Rigid Boundaries
-Overly distant leading to symptoms

Structural Therapy

Minuchin

Enactments (Structural Therapy)

Technique where therapist prompts family to reenact a conflict or other interaction- Dr. Grieme actually gets her families to fight- you see so much in an argument
One of the most important techniques to master
Occurs in three phases:
-Observation of Spontaneous Interactions
-Eliciting Transactions
-Redirecting Alternative Transactions

Benefits of Enactments (Structural Therapy)

Providing in vivo practice and experience with new interactions and family patterns
REDUCING THE ILLUSION that the problem belongs to a single person
Increasing the family's sense of competence and strength by successfully engaging in new preferred behaviors (highlighting the things they're doing well)

Structural Therapy Contributors

Salvador Minuchin
Originator of structural therapy, psychoanalytic work emphasized interpersonal relationships
Wiltwyck School
He and colleagues Dick Auerswald, Charlie King, Braulio Montalvo, and Clara Rabinowitz worked with families
Jay Haley Collaboration
1962, Minuchin visited the MRI befriending Jay Haley becoming an influential relationship developing the Structural and Strategic approaches of family therapy

Influential students & colleagues
Harry Aponte, Jorge Colapinto, Charles Fishman, Jay Lappin, and Michael Nichols,
Marion Lindblad-Goldberg
Succeeded Minuchin as Director of Philadelphia Child & Family Therapy Training Center
Developed empirically supported Ecosystemic Structural Family Therapy
Jose Szapocznik
Colleagues develop empirically supported Brief Strategic Family Therapy (BSFT)

Three main phases of structural therapy (Structural Therapy)

1. Join
The family accommodate to their style (build an alliance)- finding ways to join/align with people; establishing a safe place
2. Map
The family structure, boundaries and hierarchy (evaluate and assess)
3. Intervene
To transform the structure to diminish symptoms (address problems you identified in the assessment)

Overview of Structural Therapy

Generally therapists will alternate between phases two and three many times revising and refining
Structural therapists prefer to begin therapy with the ENTIRE family to assess the system. After assessment, therapist may meet with specific subsystems (couple, child, individual, etc.)

The Therapeutic Relationship (Structural Therapy)

Joining and Accommodating
Joining as an attitude
Mimesis- using the language of the family
Therapeutic spontaneity
--Ability to be authentic and flow with therapy
Therapist use of self
"Make it happen"
--Play what role is needed
More recent adaptation: softer style

Case Conceptualization/Assessment (Structural Therapy)

Role of symptom in the family
Subsystems- looking at different relationships/roles within the family
Cross-generational coalitions
Boundaries
Hierarchy
Complementarity- if you have a good child, you need a bad child, etc.
Family life cycle development
Strengths

Goal Setting (Structural Therapy)

Clear boundaries between all subsystems allowing connectedness & differentiation within cultural contexts
Clear distinction between the marital/couple (as LOVERS) subsystem & parental subsystem (as PARENTS)
Effective parental hierarchy
Family structure promotes develop and growth

Interventions (Structural Therapy)

Systemic reframing
--Removes the blame from one person
--Identifies circular causality
--Re-describing the problem
Enactments & modifying interactions
Boundary making
Challenging family's worldview
Intensity and crisis induction (when you're really pushing a family- bringing feelings into the mix)
Unbalancing the Family System ("Okay Mom, you can't discipline this week. Only Dad can do that.)
Expanding family truths & realities (See things that are already healthy and capitalizing on it. If family night is working well, how can we do more of that?)
Compliments & shaping competence

Working with Diverse Populations (Structural Therapy)

Excellent support for working with diverse populations
Structural family therapy employs an active, engaged approach in which the therapist often takes an expert stance in relation to the family, an approach that often fits with the values of traditional cultures

Solution Focused Therapy

Best known strength-based therapies
Positive, active approach
--Help clients move toward desired outcomes.
There are two strands of practice which share many similarities
--Solution Focused Brief Therapy
--Solution-Oriented Therapy

Solution-Based Therapies: Overview

Brief therapy approaches influenced by
Mental Research Institute (MRI)
Milton Erickson's brief therapy and trance work
Strength-based
Popular with clients, insurance companies and mental health agencies
Solution-focused
Therapists spend a minimum of time talking about the problems
Instead focus on moving clients towards solutions

Myths of Solution-based Therapy

Myth #1: They propose solutions to clients (which amounts to advice giving)
--Client identifies solutions, therapists assist client in identifying solutions and they identify exceptions to the problem (when during your life do you not talk about the problem?), describe what is already working, and identify client resources

Myth #2 They never talk about the problem
--They spend less time talking about the problem
--They take their lead from the client
--Hallmark techniques, such as exception questions require they talk about the problem

Myths of Solution-based Therapy

Myth #3: They never talk about the past
--When they talk about the past, they focus on strengths
--Talking about the past is important - it helps to identify what has worked and what has not

Myth #4: Emotions are not discussed in therapy
--They do not view the expression of emotions as curative in and of itself (as with humanistic therapies)
--Instead, emotions are used as clues for works and where they want to go

Assessing Client Strengths (Solution Based Therapy)

Strengths include resources in a person's life, personally, relationally, financially, socially, or spiritually and may include family support, positive relationships and religious faith
Clients often have greater difficulty identifying areas without problems in their life; Train clients to think positively
Strengths are assessed in two ways
--By directly asking about strengths and areas of life that are going well
--By listening carefully for exceptions to problems and for areas of unnoticed strength

Solution Based Contributors

Milton Erickson
Hypnosis
Brief
Strength-based focused
Bill O'Hanlon and Steve de Shazer's Solution-Focused
Steve de Shazer and Insoo Kim Berg
Solution-Focused Brief Therapy
Milwaukee Brief Family Therapy Center
Scott Miller, Barry Duncan and Mark Hubble, Yvonne Dolan, and Linda Metcalf

Solution-Oriented Therapy
Bill O'Hanlon
Michelle Weiner-Davis
Collaborative, Strength-Based Therapy
Matthew Selekman

Overview of Therapy Process (Solution Based Therapy)

Solution-based therapists help clients identify their preferred solution by:
Talking about the problem, exceptions, and DESIRED OUTCOMES
Working with clients to take SMALL ACTIVE STEPS in this general direction each week
This can take 1 - 10 sessions or it may take years depending on the complexity of the case

The Therapeutic Relationship (Solution Based Therapy)

Beginner's Mind
Involves listening to a clients story as if you are listening for the first time not filling in blanks with personal or professional knowledge

Echoing client's key words
Using client language often makes the problem more "solvable" and engenders greater hope

Dual track thinking
Conceptualizing client's words as well as your own reactions (Mastering therapy is making these two things work at the same time; whatever you're thinking and whatever you're hearing that are both going on at the same time)

The Therapeutic Relationship Continued... (Solution Based Therapy)

Carl Rogers with a Twist: Channeling Language
--Reflections of feeling delimit the difficult feeling, behavior or thought by reflecting on a time, context, or relational limit
-Past tense rather than chronic state or characteristic
-Partial rather than global
-Perception rather than unchangeable truth

Optimism and Hope
--Solution-based therapists assume that change is inevitable and that improvement - in some form - is always possible

Case Conceptualization/Assessment (Solution Based Therapy)

Exceptions and "What Works"
Strengths and Resources
Client Motivation: Visitors, Complainant, and Customers
--Visitors: usually brought to therapy by an outside other such as spouse, parents, courts (They don't really want to be there)
--Complainants: identify a problem but expect therapy or some other person to be the primary source of change (The mother that brings her son in and wants you to fix them)
--Customers: identify a problem and want to take action towards the problem

Solution Focused Assumptions

Every client is unique
Clients have the inherent strength and resources to help themselves
Nothing is all negative
There is no such thing as resistance
You cannot change clients; they can only change themselves.
Solution Focused Therapy goes slowly
There is no cause and effect
Solutions do not necessarily have anything to do with the problem.
Emotions are part of every problem and every solution
Change is constant and inevitable; a small change can lead to bigger changes.
One can't change the past so one should concentrate on the future

Goal Setting (Solution Based Therapy)

Goal language - positive, measurable and concrete
Meaningful to client
Interactional
Situational
Small steps
Clear role for client
Realistic
Legal and ethical

Solution-Generating Questions: Miracle, Crystal ball, Magic wand, and Time machine questions work best when therapist:
--Prepares client for a solution-generating question (like training the client to think positively from the beginning)
--Creates a compelling vision
--Asks for behavioral differences
Small steps: Scaling questions for goal setting
One Thing Different: Client-generated change (you can only ask the client to do one thing different)

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