Family Therapy

Family Therapy has fast become a necessity and a need that we all cannot do without. If you are born and you are now grown, then you certainly need therapy, it is even more impactful when the whole family opts in for therapy. In this educational summary, Sanam Naran gives us insights into the application for family therapy in modern society. 

History of Family Therapy and Assessment

The assessment of the individual and their family relationships has been and is still a constantly evolving portion of marriage and family counselling literature. According to many root sources, these include parental marital satisfaction, religious and social class similarities, orientation of family, social environment, and previous experiences with marriage and divorce. Early writings on psychology focused primarily on the perception of relationships within the older generation, and explored the notion of parental marital satisfaction predicting personal marital happiness.

Some earlier sociological approaches attempted to relate the larger social environment to marital selection and satisfaction. For example, in order for one to have a “successful” and “good” marriage, one would have to have a similar world view to that of one’s spouse, but have enough complementary personality characteristics to keep the relationship interesting. Some terms were used to describe this adjustment to the relationship within a study.

Family Therapy – Overview of Cybernetics

First order cybernetics is a mechanical systems theory that concerns itself with the focus of regulation of feedback mechanisms operant in controlling both complex and simple systems. This is the epistemology proposed by family therapy theory; it is impossible to understand individual behaviour without considering the context in which the behaviour occurs. Consider, for example, the following scenario:

“If mom and dad are having marital problems and little Lungi is acting up and throwing tantrums and Sihle is withdrawing and losing her appetite, we, as ecosystemic practitioners, do not bring Lungi for therapy or take Sihle to the GP, we look at the family in context and at what is happening in the system to cause this behaviour.”

Some postmodern theorists hold a second-order cybernetic view. This contends that within the family structure, the individual has a unique reality, which (although separate) is a legitimate reality. This view regards objective descriptions of families as mere social constructions agreed upon by social interaction. Symptoms are viewed as oppressive and therapy is concerned with assisting the family to ‘re-author’ and reclaim control over their lives.

The focus is therefore placed on the individual’s internal structure and includes his/her relationship within the system. Observers help to collectively create a new reality by interacting and resetting the inside setting of a system. The individual creates a reality unique to himself by drawing from experiences, perceptions, social insights and genetics. These elements all hold equal value and are all considered significant. Golann (1987) states that the central perspective of this system is the notion that one cannot describe or observe without modifying the subject of the observation, or by being modified in return.

Family Therapy – Systems Theory

Systems are an integral part of human life. They can be man-made, or natural, non-living or living. The notion behind systems thinking is the impossibility of studying the phenomenon of a component of a system without considering it as a part of a greater whole. Instead of breaking it up into basic components, the systemic perspective is concerned with a global perspective.

Some of the founders of the core concepts surrounding systems theory, notably Each part affects the others and by default, the system as a whole. Some of these principles, when applied to psychology, help to explore and explain patterns of behaviour. This particular approach was spearheaded by several individuals, including Gregory Bateson, Murray Bowen, Anatol Rapoport, W. Ross Ashby, and Margaret Mead (Anderson, 1997).

Concepts of Systems Theory

A group of parts interacting to construct a coherent whole form the basis of the system. For something to be considered a system, it needs to have a distinct boundary separating it from external elements. Systems can also be circuits, where the outputs of a system loop back and become its inputs. Changes in a specific part of a system will change the system as a whole.

This theory has been applied to the field of psychology, where it is known as systems psychology. In order to view psychology through the lens of systems theory, one must regard an individual within a group or system to be seeking homeostasis within that system. In order to create and maintain a system that works for everybody within it, it is imperative that each member’s needs, desires, expectations and behaviours are considered and regarded with equal importance. Therefore, when issues arise – they are attributed to the breakdown of the system as a whole, and not the deficiency apparent in one individual (Kerr and Bowen, 1988).

Systems Theory and Family Systems Therapy

This theory alludes to the fact that individuals cannot be holistically understood in isolation and must be considered within the family’s emotional unit. Bowen theorized that individuals must be viewed within their family of origin. In other words, their ancestry plays an important role in their emotional development. This concept was then developed into a popular form of treatment called family systems therapy. Effective modes

Once everybody is aware of these behaviours, and can understand the history of these behaviours, the family can appropriate new behaviours that can benefit them and the rest of the family (Kerr and Bowen, 1988).

Mental health studies have long neglected the promotion and study of health. By concentrating on mental illness, a family was considered normal only if it displayed no signs of symptoms. The assumptions about healthy families were largely utopian and speculative, extracted only from studies of severely disturbed clinical cases. The systems paradigm conceptualized the family by focusing on parent-child bonds and was linear and deterministic (von Bertalanffy, 1968). However, early family assessment and treatment succeeded to focus on some dysfunctional family processes which were thought to either cause or assist in maintaining the symptoms of the individual.

Recently, family theory and practice have been reformulated and expanded, with greater focus and recognition of how each family unit is diverse and complex and cannot be treated without considering other elements like sociocultural or even biological influences. The focus has shifted from being solely concerned with family deficits and dysfunctions, and has instead moved on to the developing of the community and the family structures within it. Family function and resilience is more important than focusing on what the family unit lacks (von Bertalanffy, 1968).

All family therapy approaches share the commonality of being founded systems theory. By combining ecological and developmental perspectives, the family is seen as a transactional system, functioning within a broader sociocultural context, as well as being placed within an ancestral lifecycle (Minuchin, 1974). All kinds of stressful events, whether they are social, environmental, or are merely the specific problems of an individual within the family system, affect all the members within the system and subsequently their relationships. Therefore, the family processes, specifically regarding the handling of problems, hold significant importance to whether an individual possesses some kind of relational or individual dysfunction (Kerr and Bowen, 1988).

In early models, therapy was focused on the problems evident and was designed primarily to alter the dysfunctional behaviour patterns. Since the mid 1980s, models have focused more on expanding strengths and potential- in an attempt to develop the strengths, instead of dwelling on the weaknesses.

Foundational family therapy models tended to concern themselves mainly with the altering of dysfunctional patterns found within the family unit. Over the past three decades, family therapy has refocused to concentrate on developing family strengths (Minuchin, Nichols, & Lee, 2006).

Structural Model

The structural family therapy model emphasizes how organizational processes are important for optimum family functioning and the well-being of its members. This kind of therapy focuses on how symptoms are embedded by an imbalance or rigidity in the organizational structure of a family unit. Instances form patterns, which define how the unit behaves going forward.

An imbalance in the family’s organizational structure can lead to problems, specifically those rooted in a malfunctioning hierarchy (for example, where there is no clear hierarchy between a parent and child). Therapy aims to strengthen the family’s structural foundation by replacing dysfunctional organizational patterns with functional ones. Commonly, symptoms are reactions to larger factors, namely environmental and developmental changes. Problems are usually resolved as the restructuring is accomplished. Therapy involves three processes: (1) joining, (2) enactment, and (3) restructuring.

The first step in this process is the therapist assuming a position of leadership within the family unit. The therapist assumes the role of an expert and works closely with the parents of the family to involve them in the process. Then, the therapist examines the family transactions by allowing the family members to present their specific problems individually.

Thirdly, the therapist will present tasks and directives to help restructure the unit’s organisational function. The therapist is an active member during sessions, blocking dysfunctional processes and encouraging healthy alliances (Minuchin, Nichols, & Lee, 2006).

Strategic/Systemic Approaches

Several techniques are used, including reframing, relabeling and the use of positive connotation. All of these techniques help to define a situation within a new context. By using these techniques, a therapist can help to redefine what has been viewed negatively, and can help all members to see that some things are born of good intention. They can help shift a rigid view or response and can be useful in changing the family’s focus from negativity towards understanding and enlightenment (Minuchin, Nichols, & Lee, 2006).

Behavioural and Cognitive-Behavioural Approaches

Behavioural approaches to family therapy developed from behaviour modification and social learning traditions (Patterson, Reid, Jones, & Conger, 1975). These approaches concern themselves with the idea of the family unit being a context from which its members are provided with critical thinking experience.

Therapy creates a space where the family members can learn how to adhere to new transactional rules regarding social behaviour. In a healthy family structure, adaptive behaviour is rewarded and acknowledged, and maladaptive behaviour is not reinforced. Social exchange principles are followed, and families are given the chance to partake in rewarding experiences that are likely to enhance and strengthen their relationships (Patterson, Reid, Jones, & Conger, 1975).

Postmodern Approaches

Postmodern perspectives highlight how therapist bias can unwittingly co-construct patterns they find in families. This kind of approach has heightened awareness about clinical views of normality. Within a post modern approach, therapists need to be aware of their own values, implicit assumptions, and biases which are all embedded in cultural norms and their own personal experiences. This kind of approach was originally based in the foundational systemic models, but broke away from many of the system’s core principles, and is now based in constructivist views on the subjective condition of reality (Hoffman, 1990).

Although people can be thought of as narrow-minded and pessimistic, this kind of therapy attempts to refocus from problems, and instead offers different ways of viewing situations. Conversational approaches emphasize how conversations can be therapeutic in their attempt to “restory” an event (Walsh, 2012). The core of this therapy is founded on the notion of a subjective reality that is socially constructed through language.

The client has a story, which is the main focus, and the therapist will help to construct meaning throughout the process. Because the therapists view is also subjective, the therapist will strive to listen carefully and allow the client to arrive at his/her own conclusions, simply guiding him/her through the process. This is achieved by asking strategic questions, and wondering about alternative possibilities. In this way, therapy attends to how language and meaning are vehicles that reflect the larger social context (Hoffman, 1990).

Solution-focused approaches

This fast-paced kind of approach intends to avoid overcomplicating matters, and contends that complicated problems do not always need complicated solutions. These approaches will often apply solutions that have worked before, and will not address the broader implications of the matter at hand. Therapists will use formulaic techniques like scaling or asking the “miracle question”. They tend to focus on desired outcomes and the techniques needed to achieve them (McFarlane, 2002).

Family Psychoeducational Approach

It views the family structure as an ally and supports families whilst they are adapting to the situation. It also provides the family with concrete guidelines when dealing with crises. It is primarily concerned with stress reduction and education, which it achieves with proactive problem-solving (Anderson, Reiss, & Hogarty, 1986).

Families are considered as valuable collaborators and this kind of approach does much to correct the marginalization so apparent in traditional psychiatric settings. Therapy will always include the family, and will extend to consultations, workshops and groups where families can meet other families going through the same treatment. (McFarlane, 2002).

Intergenerational Approaches

Within this approach, healthy spousal and parental functioning are seen as largely influenced by how the individual’s family of origin functioned. Here, the process is focused on a shared projection that has a direct influence on choice of partner and how an individual conducts parent-child transactions. In healthy pairings, individuals will be able to be committed, intimate and will be able to withstand disappointments and differences within the relationship.

In a healthy family unit, parents can focus on their roles as parents, without having any of their own intrapsychic conflicts or unfulfilled needs distract them. They are free to concentrate on their child’s developmental priorities.

All dysfunction within the family and couple is considered a result of past losses or conflict which interferes with a realistic means to response to others (McFarlane, 2002). Situations that arise are viewed from the lens of one’s own inner world and this process adds to their distorting. Symptoms like irrational role assignment and scapegoating can be the result of the attempt to externalize or master issues through the current relationship.

Significant loss and or trauma may affect the family system in its entirety – causing emotional upheaval in all members and placing strain on their relationships. Treatment explores the connection between the family dynamics of multiple generations and their influences on current issues. The therapist will promote awareness of emotional processes, and will work on improving communication between members in order to work through unresolved issues and rectify the negative patterns of the past (Framo, 1992).

This process, which serves to build empathy within the couple or family unit, may include extended members of the family, or may consider working on changing relationships within each session.

Minuchin’s 4 Step Model of Couples And Family Assessment

The therapist that is orientated mainly within the construct of systems, assessment is mainly used to explore and interrogate a family’s perspective on its issues. This perspective is then used to improve the family member’s interactions.

The first step within this model often is the therapist questioning whether the family locates the main problem to be exclusively within one of its member (or the identified patient). Through probing but respectful questioning, the therapist seeks to broaden the focus from the patient in question, to the relational patterns of the family unit. These questions are designed to garner information about the condition whilst opening up the perceived certainty about the problem (Minuchin et al, 2007).

A therapists opening question must seek to allow the family members a space to tell their stories and express their feelings, whilst gaining their trust. However, a therapist must not accept the family’s description of their issues as located solely within one member (Minuchin et al, 2007).

Secondly, the therapist must explore the way members may be responding to the suspected problem, and how they may be perpetuating it. This is done in a manner that does not support the notion of blame-shifting. A therapist can help each member of the family become their own agent of change by allowing them to see how their actions may be perpetuating problems. This technique requires each member to overcome the natural resistance to being blamed (Minuchin et al, 2007).

Thirdly, this model will briefly explore the past in order to help members understand and identify why they may have unproductive ways of responding to each other. The primary distinguisher between advice-giving and therapy is that a therapist will assist a family in uncovering why things are unhealthy for it instead of telling it to cease. Understanding past experiences helps to make current behaviour more contextual and allows the client to understand why he or she is experiencing current issues (Minuchin et al, 2007).

The forth step in this model is how this kind of assessment can be useful. After pinpointing and developing a clear understanding of where the issues lie, the therapist and the family discuss the things that need to change and review which members are willing and unwilling to do what (Minuchin et al, 2007).

The Olson Circumplex Model

This model is highly attractive to therapist working with families under severe stressors. The Olson Circumplex Model (Olson, 2000) makes use of flexibility, cohesion and communication skills to define family interactions. Based on the conceptual clustering of multiple concepts designed to describe family and couple dynamics, the model “is specifically designed for clinical assessment, treatment planning and research on outcome effectiveness of marital and family therapy” (Olson, 2000, p.144).

This model suggests that “balanced levels of cohesion and flexibility are most conducive to healthy family functioning. Conversely, unbalanced levels of cohesion and flexibility (very low or very high levels) are associated with problematic family functioning” (Olson, 2011, p.65). The model can provide a vehicle for discussing these concepts with families and couples and can help to give them tools for managing stress in future.

Olson (1993) developed some self-report instruments in order to adequately assess the three major dimensions of the Circumplex Model and other related concepts,. The self-report instrument called the Circumplex Assessment Package (CAP) provides the insider’s perspective, whereas the Clinical Rating Scale (CRS) provides the outsider’s perspective. Both are useful, however can sometimes provide data that seems conflicting. However, the data can be useful when capturing the complexity of the family and marital systems.

Assessment: Multi-Method, Multi-person, Multi-trait and Multi-system Levels

The Multi-method assessment type uses the self-report scale, which provides insight into the workings of each individuals mind, using both the therapist and the subject’s observations of the same system. Because these both provide separate perspectives, this method can be extremely useful when working with families (Olson, 1986). Multi-person assessment can also be used to garner a holistic view of the family system, as each member does not always agree on the description of the system. This kind of assessment can provide a complete picture of the system, whilst highlighting levels of agreement.

Multi-trait assessment is based on the three central dimensions of the Circumplex Model: cohesion, flexibility and communication. A therapist will ask the family members who they consider to be a part of their family. By asking this question, one can establish who is psychologically and physically present within a system (Coupland, Serovich & Glenn, 1995). This is important given the constantly changing diversity of family forms, especially when divorce and remarriage are considered.

Darlington Family Assessment Framework

This assessment framework relies on four pillars. These include: the child perspective, the parental perspective, the parent- child perspective and the whole family perspective. All these perspectives are examined in turn, with the view that just as the individual should be examined within a context, so should the family. This dimensional framework provides a useful means of describing families in a way that helps to generate hypotheses (Wilkinson, 2002). Using multiple perspectives enables causal links (both linear and circular) which are perceived more readily between problems in different parts of the family system.

The main goal of this interview is to detect problems by viewing how they are perceived by separate members of the family. This creates a dialogue and helps the therapist create a therapeutic contract with the family.

A rating scale then accompanies the structured interview. Its main function is to provide a means for the summary of a case. It can be used independently of the interview although it is recommended that initially it should be used in conjunction with it (Wilkinson, 2002).

The McMaster Model

This model is based on a systems theory. The assumptions of this theory are as follows:

This model does not cover every single aspect of the family function, but does identify many dimensions which have been found to be important when dealing with clinically presenting families.

In order to understand family structures, the focus is on assessing six elements of family life: problem-solving, roles, communication, behaviour control, affective responsiveness and affective involvement. The family unit is then evaluated to determine its functionality within these dimensions (Epstein, Baldwin & Bishop, 1983).

The McMaster model also recognizes dysfunctional transactional patterns, which refer to common interactions that are characteristic of the family. Generally these sets of behaviour serve to decrease anxiety, but at the expense of the family function (Epstein et al., 1983).

The Family Assessment Device (Epstein et al., 1983) consists of subscales that assess the six dimensions of the McMaster Model. It also includes a general functioning scale which assesses the overall level of the family function. Family members rate how well specific statements describe their family by selecting from among four responses: strongly agree, agree, disagree and strongly disagree (Epstein et al., 1983).

Family Process and Content Model

The Family Process reviews the functions that serve to organize the family unit. These functions include how a family adapts to new circumstances. Decision making, communication skills, flexibility, coping mechanisms, child rearing, problem-solving, leadership, tolerance, assertiveness, and self-presentation are all factors that are considered (Epstein et al., 1983).

Family Social Context

The FPC Model is contextual. The changing family system continues to be affected by various external factors and crises, be they social, economic, religious or political. These are permanent changes and the family must develop ways to deal with them. Families should integrate their system within the social context, and if they cannot, they will be rejected socially (Deacon, 1998). Therefore, the more integrated the family, the better performance the family will have in context. Family immigration is an example of a family reaction to a social condition (Epstein et al., 1983). External factors can assist the family in repairing its functions.

Family Types

Types of families can be identified by basing theory on the family content and process dimensions (Samani, 2010). Three general categories of family types are healthy families, unhealthy families and problematic Families:

1. Healthy families: This family type has well-developed processing functions and good family contents. This type can adjust to situations and has a high efficacy for child rearing and general satisfaction (Samani, 2010).

2. Unhealthy families: This type of family cannot manage its problems efficiently and do not have enough content to provide a healthy platform for making a family (Samani, 2010).

3. Problematic families: This type of family has good content in only one, specific dimension. One type of family group might have good content in a specific area, but lacks the skill to use family processes. The other might have the skill but not enough content (Samani, 2010).

Family Assessment

Family Assessment is utilized for a set of goals, whilst classifying a family type. As Johnson (1996) mentions, the family assessment must be able to recognize and describe family strengths and problems

Family Therapy In South Africa

In the decade of 1960, Family Therapy began and was conducted by a few professionals in South Africa. These professionals had been influenced by several studies world-wide.

During this time Mason and Shuda (1996) describe how social work in particular became concerned with the plight of the multi-problem family and began to attempt family intervention. According to Kaslow (2000), it was the academic departments of psychiatry and social work that initially began to apply these varying models and techniques of family therapy.

During the period between 1976 and 1981, there was much consolidation and growth, specifically in the field of family therapy in South Africa. Since 1981, there has been an immense amount of growth in education in the form of workshops; conferences and supervision in South Africa, because of international knowledge and experience brought to it. The first international conference of the South African Institute of Marital and Family Therapists was held in Durban in 1981, enhancing the credibility and visibility of family therapy (Mason et al., 1996).

Multicultural Assessment

South Africa as a society is comprised of a variety of differing social, ethnic, and cultural groups. There is also a considerable socio-economic diversity. The population ranges from well-educated and affluent, to extremely rural and illiterate. In the opinion of the researcher, this provides both opportunities and obstacles to intervention with families in distress, requiring an appreciation of a multi-cultural perspective to facilitate appropriate intervention with diverse client families.

While family therapy is undertaken with diverse population groups at Family Life Centre, it is only at the Head Office in Parkwood which has the facilities and personnel resources to deliver this method of intervention. The geographical location attracts the Western or Westernised urban populations (Mason et al., 1996). Thus intervention of this nature is restricted to a small sector, and its universal application may not prove to be the most appropriate intervention. Difficulties concerning the availability of resources and services in the wider communities and rural areas remain a challenge.

Culture involves both conscious and unconscious aspects and practices (Mason et al., 1996). According to Chope (2005), the broader cultural context is the family’s ethnic heritage, a heritage that is steeped in the norms and values transmitted over generations that provided the family with an identity and expectations regarding behaviour. It is through culture that we understand and organise our experiences of the world, while ethnicity provides a common ancestry, historical continuity and sense of belonging.

Thompson, Rudolph& Henderson (2004) describe the fairly recent entry of families of many different cultures into the family therapy arena. Although these authors are exploring this in the context of the USA, this aspect has as much relevance for South Africa. These authors suggest that therapists need to familiarise themselves with the customs, styles, norms, communication patterns and standards of behaviour of diverse groups. This requires openness to the uniqueness of every family and how the family responds to distress in relation to its culture.

Current counselling practices reflect Western, white middle-class values that cannot necessarily be applied to different ethnic groups (Thompson et al., 2004). Chope (2005) concurs, stating that family therapists are often highly educated and are typically middle-class, socialised in terms of mainstream values regardless of their ethnic origin. These values may be at odds with the values of some families they encounter, again highlighting the importance of the postmodern view of self-awareness and reflexivity.

Chope (2005) refers to the “culturally encapsulated” therapist who is insensitive to difference, and makes assumptions about groups of people. This therapist may even display overt or covert prejudice that negatively impacts on the therapeutic process. Chope (2005) states that family therapists need to be aware of their own biases and values in order to work with culturally diverse families.

This kind of exploration is both emotional and intellectual and requires an acute awareness of one’s own systems of belief and requires an awareness of own cultural heritage. There must also be a cultural sensitivity and respect for differences (Thompson et al., 2004).

Conclusion

In order to understand how a family functions, it is crucial to use assessment strategies that are appropriate to both cultural background and socioeconomic level of the family. Assessment techniques can be extremely beneficial in helping the therapist to collect information about family problems, family organization, family functioning, family strengths and the goals or changes amongst family members.

The reviews of different literature show that therapists require training in how to apply the assessment data. Discussion of assessments and suitable intervention approaches dependent on the family’s cultural needs must also be considered. This process is ongoing and is subject to continual revision with the development of new information within the life space of the family unit (Minuchin et al, 2007) .