FAMILY THERAPY

& COUPLE
THERAPY

Speaker: Dr. Abhijith

C/P: Dr. Siddharth

FAMILY THERAPY -DEFINITION

Family therapy is a mosaic of techniques, all of
which have the shared goal of direct alteration of
maladaptive family processes.

Family therapy is psychotherapy that directly

involves family members in addition to the
identified patient, and/or explicitly attends to the
interactions among family members

FAMILY & CHILD DISORDER

Family promoting disorder

Family responding to disorder

Disorder as an indicator of family

dysfunction

UNIQUE THERAPY
Family Vs Individual
Role of context
Deviation from linear medical
perspective.
Differences in confidentiality
and transference
Family Vs Group
Biological relationship &
hierarchy among members.
Influential shared past history.
Internalized world of members

ORIGIN OF FAMILY THERAPY

Child guidance clinics of early 1900s
& family intervention ancillary to
psycho analysis.
Nathan Ackerman founder of
family therapy
John bell, Carl Whitaker, Bowen &
other psychoanalysts turned to
family therapy
Groups to study families with
schizophrenia

RISE OF FAMILY THERAPY

60s & 70s Enthusiasm
Bertalanffy & Minuchin
Shift from Schizophrenia to other
disorders.
Anti medical & anti individual stance
Specialized institutes and schools of
family therapy.
European contribution by Milan group,
skynner & Horst Richter

MOVE TOWARDS INTEGRATION

Bridge between child psychiatry & Family therapy.
Decline of schools & Recognition of eclectic
therapy.
More objective research
Information regarding efficacy in specific disorders
& choice of therapy.

DEVELOPMENT OF FAMILY
Living together.
Accepting parental roles.
Accepting role of child.
Introducing child to outside institutions.
Accepting adolescence & changes.
Allowing experimenting with independence.
Preparing to launch.
Letting go & Empty nest.
Accepting retirement.

NORMAL Vs ABNORMAL FAMILY

Individuation Vs Enmeshment
Mutuality Vs Isolation
Flexibility Vs Rigidity
Stability Vs Disorganization
Clear Vs Unclear perception
Clear Vs Unclear roles
Role reciprocity Vs Conflict
Clear Vs Unclear boundaries.

INDICATIONS
Evidence of family dysfunction
Evidence that family dysfunction related to clinical
presentation.
Relationship & interactional problems
Failure of other treatments
Favorable Evidence base

CONTRAINDICATIONS
Practical / geographical limitations.
Poor therapist match.
Severe medical illness.
Incapacitating psychiatric disorders.
Escalating physical harm.
Working with divorced parents.

CLARKIN & MOODIE

DECISION TREE
When family assessment indicated?
All CAP patients
Presenting problem & clinical distress related to
family problems.
More than one family member seek help.
Patients improvement coincides with deterioration
in others & relationships.

WHEN FAMILY THERAPY REQUIRED?

Parent child relationship problems.
Communication deficits.
Adolescent antisocial behavior.
Adolescent separation problems.
Child controlling parent.
Failure of other treatments.
Motivated family.
More than one family member requiring treatment.

MODELS FOR ASSESSMENT

MCmaster model 1978
Process model of family functioning 1984
Minuchins structural model 1974
Tseng & Mcdermotts triaxial scheme 1979
Olson & Russells Circumplex model 1979
The Beavers model - 1981

PROCESS MODEL
Problem solving
Role performance
Communication
Affective involvement
Control
Values & norms

TRIAXIAL SCHEME
Family development dysfunction
Developmental dysfunction
Developmental variations

Family subsystem dysfunction

Spouse dysfunction
Parent child dysfunction
Sibling dysfunction

Family group dysfunction

Structural functional dysfunction
Social coping dysfunction

STAGES OF ASSESSMENT
Initial contact
Establishing rapport
Defining desired outcome
Review history, determine present developmental
stage & genogram
Assess current functioning
Develop diagnostic formulation
Offering feedback
Arranging further clarifications & referrals
Treatment proposals.

SCHOOLS OF FAMILY THERAPY

Systemic
Structural
Strategic
Psychodynamic
Cognitive behavioral
Experiential
Extended family systems
Communicational
Group family therapy

SYSTEMS THERAPY
Von Bertalanffy 1969
Whole is more than sum of its parts
Open Vs Closed systems
Steady state & equifinality
Konrad Lorenzs experiment - Context
Circular causality
Subsystems & suprasystems.

SYSTEMS THERAPY
Cybernetics (Weiner, 1961):
- systems are viewed as self-correcting, influenced in an
ongoing way by feedback.
- feedback is the process by which a system gains
information to self-correct to maintain a steady state or
move towards a goal
- homeostasis is the powerful force moving the system
toward a steady state

SYSTEMS THERAPY
Morphogenesis natural force moving the system toward
change
Autopoesis internal structure of the living system
determines its behavior

STRATEGIC THERAPY
Most purely systemic of the family therapies
Ineffective problem solving becomes a pattern & a
problem
Therapist sets clear goals & designs strategies for each
specific problem
Therapist maintains neutrality stance

STRATEGIC METHODS
Content & context reframing
Paradoxical interventions directives are offered which
if acted on would move the family in the opposite
direction from that which is desired
Use of metaphor & humor
Change of interaction sequence & rituals.
Positive connotation

STRATEGIC METHODS
MRI (Mental Research Institute) / Palo Alto model
Haleys problem solving therapy
Milan systemic therapy
Solution-focused therapy

STRATEGIC METHODS
Milan systemic therapy
- team situated behind a one-way mirror
- team forms a hypothesis about family to be modified
over the course of treatment
- during a break in session, team formulates intervention
- intervention through:
> positive connotation
> ritual prescription

STRATEGIC METHODS
Solution focused therapy:
- assume that clients want to change & reject the notion
of deeply ingrained pathology
- help clients begin to think in terms of solutions rather
than problems
- DeShazers miracle question

STRUCTURAL THERAPY
Salvador Minuchin
Dealing with subsystems
3 dimensions of structure
1. Boundaries rules defining who participates & how, who is
in & who is out of an operation regulating contact
- Flexible or Rigid
- Enmeshed or Disengaged
2. Power relative influence of each family member on the
outcome of an activity

ALLIGNMENTS
3) Alliances joining or opposition of one member of a
system to another in carrying out an operation

)Normal alignment
M

C
)Pathological - Triangulation, Coalition, Detouring

PSYCHO DYNAMIC FAMILY THERAPY

Nathan Ackerman, James Framo & Virginia satir
Passive therapist
Free association
Insight oriented
Shared exploration of past experience, current
distortions & role confusions.
Issue of transference contamination

COGNITIVE BEHAVIORAL
Gerald Patterson & James Alexander
Classical & operant conditioning
Social exchange theory individuals strive to maximize
their outcomes to increase the rewards they receive and
decrease the costs.
Alter dysfunctional thought process
Behavioral analysis, empowering parents & differential
reinforcement

EXTENDED FAMILY SYSTEMS

Murray Bowen
Three generational approach
Emotional & relationship systems
Resolving intergenerational issues
Foster differentiation of undifferentiated ego mass.
Crux of Bowen approach differentiation of self,
amounting to the ability to distinguish thoughts &
feelings

EXPERIENTIAL THERAPY
Carl Whitaker & Walter Kempler.
Existential human encounter with the family
Emphasis on felt experience ie restoring liveliness &
connection
Primary instrument is therapist, using self as an
instrument toward change
Facilitator encourages growth of family.

ECLECTIC THERAPY
Conjoint Vs Concurrent.
Assessment & formulation.
Crisis stabilization.
Parent education.
Family interventions.
Tailoring therapy.
Individual perspectives.
Marital therapy.
Sibling interventions.

COMMON HURDLES
Culturally inappropriate.
Minimal father involvement.
Poorly defined role for siblings.
Counter transference.
Inaccurate formulation.
Inattention to influential relatives.

CLINICAL APPLICATIONS
Psychosis
Engagement & adherence
enhancement.
Psycho education & Family
collaboration in therapy.
Reducing Expressed emotions.

Depression
Parental education
Building individual competence &
attachment
Limit setting for acting out
Cognitive behavioral strategies.

CLINICAL APPLICATIONS
Anxiety disorders
Reduction of fear & vulnerability
Dealing with expectations.

Substance abuse
Interactional problems
Parental substance abuse

Eating disorders
Structural techniques.
Gender issues & perfectionism

Impulse control disorders

Child abuse

DISRUPTIVE DISORDERS
Education & family involvement.
Responsibility & accountability for child.
Limit setting.
Clear Consistent rules.
Special plans for impulsivity.
Empowering parents.
Resolving power conflict.

CONTEMPORARY ISSUES
Emphasis on biopsychosocial approach.
Integration of individual & family
approaches.
Parent management training
Variations in family compositions.
Culture & family therapy.
Ethical issues.

CURRENT LIMITATIONS
Reluctance of family therapists to
accept current diagnostic systems.
Power of biological wave.
Managed care limitations.
Impending fragmentation of care.
Absence of valid nosology/
classification of relationship
disorders.
Absence of objective outcome
assessment.

Couple therapy

Definition
A form of psychological therapy used to treat
relationship distress for both the individuals and
the couple.
Purpose: to restore a better level of functioning in
couples.
Focus:
identify the presence of dissatisfaction,
devise and implement a treatment plan.

The focus is remedial and the therapy

typically occurs during the long phase of the
relationship that follows some sort of a
symbolic ritual affirming a long term
commitment
If the focus is non-remedial, then it is on
the enrichment of the relationship

Four phase conceptual history

Phase I pioneer stage- Atheoritical marriage
counseling formation (1930-1963)
Phase II psychoanalytic experimentation (19311966)
Phase III family therapy incorporation (19631985)
Phase IV refinement, extension and integration
(1986- present)

Phase I Pioneer stage

Early marriage counsellers
Approach was typically very focused, very
short term and didactic
Clients were newly marrieds, premarrieds
seeking guidance about everyday facets of
life

Not severely maladjusted /suffering

Treatment format- rarely had conjoint
sessions
Only by the end of 1960s did they begin to
have conjoint sessions
No empirically tested principles and no
theoretically derived foundation to operate
clinically

Phase II- Psychoanalytic

experimentation
Marital conflict based on the neurotic
interactions of the partners- product of
psychopathology in one or both partners
Obendorf (1931)- interlocking neurosis in
symptom formation and folie a deux in
couples and consecutive psychotherapy of
marital partners
Mittelman (1948)- concurrent treatment,
then joint sessions to find out the truth

Martin (1965)- collaborative therapy and

combined treatment
Increasing sense among therapists that
something was missing from the dominant
conceptualizations of both marital conflict
and of requisite therapeutic interventions
Ambivalent transition towards conjoint
approach

Psychoanalytic couples therapy out of race

for nearly two decades.
Reasons:
) Lack of effective interventions
) Family therapy movement

Phase III- family therapy

incorporation
Four influential voices
Jackson
Virginia Satir
Murray Bowen
Jay Haley

MRI (Mental Research

Institute) / Palo Alto model
Jackson, Watzlawick, Weakland
Derived from a mix of systems theory,
cybernetics and study of communication
processes
Reframing therapist actively creates a
new & different understanding of old events
that has a more benign meaning.
Paradoxical interventions

Virginia Satir
Self esteem and ones quality of
communication exist in a circular
relationship
Ultimate goal of therapy was to foster
greater self esteem and self actualization
through clarity of self expression, self
perceptions, increasing self awareness,
removing protective masks and accepting
and valuing differences- goals were growth
and not stability

Murray Bowen
Emphasized the marital dyad as the central
treatment unit
Differentiation of self- the central concept,
i.e. the ability to distinguish between
thoughts and feelings. Differentiation within
self and differentiation from others.
Equivalent to psychological health and
precondition for marital or couples health

Jay Haley
Central relational dynamic of marriage
involved power and control
Problems arose in marriage when the
hierarchical structure was unclear and there
was lack of flexibility or the relationship
was marked by rigid symmetry or
complementarities

Phase IV- formative stage

Refinement:
) Behavioral marital therapy
) Emotionally focused couple therapy
) Psychodynamic couple therapy

Extension:
) Treatment of psychiatric disordersdepression, alcoholism, anxiety
) Preventive interventions
) Integration- two major integrative patterns
) Integration of marital therapy approaches
and couple therapy and brief therapy &
integration with the broader world of
psychotherapy

Therapeutic Formats
Conjoint sessions- couple with a single or
two therapists.
Concurrent sessions-individual therapy for
each partner by a single therapist.
Collaborative sessions-individual therapy
for each partner by two different therapists
who confer with each other.
Couples group therapy.

Different formats
H+W

T
Conjoint

T
Concurrent

T1

T2

Collaborative

Sagers contract theory

Contract- set of assumptions and
expectations of self and partner with which
each person approaches the relationship
Reciprocal in nature
Not explicit but each partner behaves as if
it is explicit

 Much of this is not conscious even to the

person making the contract and there are
chances of confusions
Three level contract
1. Expectations of marriage as an institution
2. Expectations of what I as a person need
form you as a person
3. External foci of problems

Three levels based on the degree to which

it is shared with the partner
1. Verbalized
2.Secret
3. Beyond awareness
The contracts are dependant on age,
situation and partner

Marital conflict results from incongruent or

unfillable contracts
The complexity in marital conflicts is
primarily due to the level of the contract
which involves a persons intra psychic
needs and is beyond the awareness.

Object relations theory

Describes the process by which conflicts
which the child has with the parents are
handled by introjecting the relationship
and dealing with it at an intrapsychic level.
The child introjects both parts/ halves of
the conflict.

In projective identification, the adult

projects on to the partner an introjected
part of the self that was repressed or
repudiated.
Important to recognize the needs these
projective identification and collusion serve
Such relationships are tightly bonded even
if unpleasant

Behavioural approach
Views marital satisfaction/ dissatisfaction
in reinforcement terms.
Decreased mutual reinforcement increases
mutual punishment distress.
Plan: increase the level of reinforcement
Behavior exchange
Communication training
Problem solving training.

Behavioral approach
1.Preparations for behavior change:
Presenting complaints and ventilation) empathic listening
) Balance between listening too much and
listening too little
) Presenting complaints useful to
differentiate between clients

Building the therapist client relationship

Structuring client expectations- replacing
medical model with a more suitable set of
expectations
Structuring therapist client interactionoutline the general format during the initial
session itself- who, what, when, how, where
and why

Behavioural approach
2. Discrimination training and pinpointing of
behavioral objectives
) Specify annoying behaviors
) Keep daily records
) Purpose is to increase cause-effect patterns
in their relationship
) Therapist should provide detailed feedback
regarding their interaction

Behavioural approach
3.

Operant principles and behavior change

procedures

Positive, negative reinforcers, punishments and

withholding desired behaviors
Major social reinforcement patternsreciprocity and coercion
Building positive behaviors- therapist reinforces
desired behavior through continuous or
intermittent reinforcement schedules

Schedules of reinforcement fixed interval,

variable interval, fixed ratio and variable
ratio
Extinction- no reinforcements are provided
for a persons response

Behavioural approach
4. Increasing positive interaction through
recreational time
Improve the quality of leisure and moderate
the quantity of time spent together
5. Stimulus change and stimulus control
procedure

6. Classical conditioning behavior change

procedures
Used to explain how an emotional or
behavioral response can come to be elicited
by an environmental stimulus that initially
did not elicit that response
Counter conditioning- systematic
desensitization

Behavioural approach
7. Building communication skills
couples either do not like the messages
they are receiving from the spouses or their
messages are being misinterpreted;
communication is a set of skills, so they
have either learned dysfunctional skills or
have failed to learn proper skills.
educational approach used to teach them
new and effective ways of interacting

Behavioural approach
8. Building skills in assertion and problem
solving
Assertion training intended to substitute
direct non coercive communication for
aggressive , coercive and avoidant, passive
communication

Problem solving requires positive

interpersonal environment where there are
exchanges which are rewarding rather than
punishing and also specific problem solving
skills.

Structural and Strategic therapy

People interacting within a context- both
affected by it and affecting it
Family life cycle and developmental stage are
important both in diagnosis and in defining
therapy strategy
Symptoms both system maintained and system
maintaining
Couple or family can change if the overall
context is changed. If the individual must
change then the system must change.

Structural therapy
Primary concept- proximity/ distanceboundaries
Continuum of enmeshment disengagement
Thrust of structural therapy is toward
differentiating enmeshed couples and
increasing the involvement of couples who
are disengaged

Techniques
Any therapeutic intervention made by the
therapist necessarily includes a structural
component

Treatment goals: more adequate family

organization which will maximize growth
potential of each of the family members

Diagnostic purpose involves joining and

knowing a couple, accepting and learning
its style

Interventions
Therapists think visually- in terms of maps,
alliances, boundaries, etc
Plan is gauged against therapists
knowledge of what is normal at a given
stage in development
Emphasis placed on process than contentpatterns give clues about proximity and
distance
The desired change must take place within
the actual session

Therapist does not allow a spouse to talk

about the other spouse
People change for three reasons:
(a) reality perception has changed,
(b) alternative possibilities appeal to them,
(c) once alternative patterns have been tried
and tested, new relationships appear selfreinforcing

Strategic therapy
Symptom regarded as a communicative act,
appears when a person is an impossible
situation and is trying to break out of it
The problem is not the identified
patient rather the crisis stage the couple
has entered
Goal of the therapy is to change the
dysfunctional sequence of behaviors shown
by the couple

Techniques
Paradoxical intervention: those which
appear absurd because they exhibit an
apparently contradictory nature, such as
requiring clients to do what they have
already been doing rather than requiring to
change, which is what everyone else is
demanding

Positive interpretation
Ascribe positive motives to clients
Primarily because negative , blaming,
criticism tend to mobilize resistance
Certain groups have held the belief that all
symptoms are highly adaptive for the
couple, i.e everything that everybody does
is for good reason and is understandable

Cognitive behavioral couple

therapy
Interpretation of partners behavior matters
along with behavior patterns.
Dysfunctional cognitions, like always and
never.
Cognitive restructuring of
Selective attention, assumptions.
Expectations and attributions.
All or none phenomenon

Emotionally focused couple

therapy (Insight oriented)
Views distress in terms of attachment
theory.
Failure of an attachment to provide a
secure base distress strong primary
emotions secondary reactions.
Re-establishment of attachment bonds
Access and reprocess the emotional
experience of partners.
Restructure interaction patterns.

Indications for couples therapy

Relationship problems.
Individual disorder:
Partner assisted intervention.
Disorder-specific couple intervention
General couples therapy for improving
functioning of the individual and the
relationship as well

Predictors for success

Couple variables:
Initially had better relationships
Wider array of strengths
Absence of the four horsemen: criticism,
defensiveness, contempt, stonewalling.
Therapist variables:
Positive therapeutic alliance
Therapist gender.

Issues of concern
Therapeutic alliance:
Multiple alliances
Triangulation with the therapist
Influence of the family system on the
therapist.
Special issues:
Spouse abuse
Same sex couples

Positive outcome
Achieved with the following:
1.Resemblance of the couple to the couples in
the general population.
2.Reduction of distress, increased
satisfaction.
3.Separation and divorce can also be positive
outcomes for some couples.

Conclusion
Couple therapies are the treatments of choice for
couple difficulties, as well as are essential
components in providing comprehensive treatment
for other individual disorders as well.
Currently, no convincing evidence that any one
couple therapy is better than another.
The question of which therapies might be best for
which couples remains to be addressed.
Goal is on reducing distress and improving marital
satisfaction, rather than trying to change
individuals

Future directions
Need for further research in matching couple
problems to the therapies they receive.
Developing more powerful interventions in the
currently existing therapies rather than developing
new therapies.
Conducting more thorough and long term
evaluation of the effects of intervention.

THANK YOU !