Monday, January 11, 2010

Family Systems Therapy

Contributors to Family Systems Theory:
Family systems therapy is represented by a variety of theories and approaches, all of which focus on the relational aspect of human problems.  During the 1950s systemic family therapy began to take root.  During the early years of its evolution, working with families was considered to be a revolutionary approach to treatment.
The Family Systems Perspective:
Perhaps the most difficult adjustment for counselors and therapists from Western cultures is the adoption of a “systems” perspective.  Our personal experience and Western culture often tells us that we are autonomous individuals, capable of free and independent choice.  We are born into families – and most of us live our entire lives attached to one form of family or another.  Within these families, we discover who we are; we develop and change; and we give and receive the support we need for survival.  We create, maintain, and live by often unspoken rules and routines that we hope will keep the family (and each of its members) functional.
A family systems perspective holds that individuals are best understood through assessing the interactions between and among family members.  The development and behavior of one family member is inextricably interconnected with others in the family.  Symptoms are often viewed as an expression of a set of habits and patterns within a family.  It is revolutionary to conclude that the identified client’s problem might be a symptom of how the system functions, not just a symptom of the individual’s maladjustment, history, and psychosocial development.  A client’s problematic behavior may:
1. serve a function or purpose for the family
2. be unintentionally maintained by family processes
3. be a function of the family’s inability to operate productively, especially during developmental transitions, or
4. be a symptom of dysfunctional patterns handed down across generations.
The one central principle agreed upon by family therapy practitioners, regardless of their particular approach, is that the client is connected to living systems.  Attempts to change are best facilitated by working with and considering the family or relationship as a whole.  It is not possible to accurately assess an individual’s concern without observing the interaction of the other family members, as well as the broader contexts in which the person and the family live.  Because the focus is on interpersonal relationships, Becvar and Becvar (2003) maintain that family therapy is a misnomer and that relationship therapy is a more appropriate label.
The family is viewed as a functioning unit that is more than the sum of the roles of its various members.  The family provides a primary context for understanding how individuals function in relation to others and how they behave.  A systems orientation does not preclude dealing with the dynamics within the family, but that this approach broadens the traditional emphasis on individual internal dynamics.  Systemic therapists do not deny the importance of the individual in the family system, but they believe an individual’s systemic affiliations and interactions have more power in the person’s life than a single therapist could ever hope to have.
The Development of Family Systems Therapy
Adlerian Family Therapy:  Alfred Adler was the first psychologist of the modern era to do family therapy.  Adler was the first to notice that the development of children within the family constellation (his phrase for family system) was heavily influenced by birth order.  He believed it was the interpretations children assign to their birth positions that counted.  Adler also noted that all behavior was purposeful – and that children often acted in patterns motivated by a desire to belong, even when these patterns were useless or mistaken.
Rudolf Dreikurs refined Adler’s concepts into a typology of mistaken goals and created an organized approach to family therapy.  A basic assumption of modern Adlerian family therapy is that both parents and children often become locked in repetitive, negative interactions based on mistaken goals that motivate all parties involved.  
Multigenerational Family Therapy:  Murray Bowen was one of the developers of mainstream family therapy.  His family systems theory is sometimes referred to as multigenerational family therapy.
Bowen’s observations led to his interest in patterns across multiple generations. He contended that problems manifested in one’s current family will not significantly change until relationship patterns in one’s family of origin are understood and directly challenged.  His approach operates on the premise that a predictable pattern of interpersonal relationships connects the functioning of family members across generations.  Within the family unit, unresolved emotional fusion to one’s family must be addressed if one hopes to achieve a mature and unique personality.  Emotional problems will be transmitted from generation to generation until unresolved emotional attachments are dealt with effectively.  Change must occur with other family members and cannot be done by an individual in a counseling room.
One of Bowen’s key concepts is triangulation, a process in which triads result in a two-against-one experience.  A major contribution of Bowen’s theory is the notion of differentiation of the self.  Differentiation of the self involves both the psychological separation of intellect and emotion and independence of the self from others.  In the process of individuation, individuals acquire a sense of self-identity.  This differentiation from the family of origin enables them to accept personal responsibility for their thoughts, feelings, perceptions, and actions.
Human Validation Process Model:  Virginia Satir began emphasizing family connection.  Satir discovered the power of family therapy, the importance of communication and meta-communication in family interaction, and the value of therapeutic validation in the process of change.  In her view, techniques were secondary to the relationship the therapist develops with the family.  Her experiential and humanistic approach came to be called the human validation process model, but her early work with families was best known as conjoint family therapy.
Experiential Family Therapy:  Carl Whitaker was a pioneer in experiential family therapy, sometimes known as the experiential-symbolic approach.  Whitaker stressed choice, freedom, self-determination, growth, and actualization.  Whitaker stressed the importance of the relationship between the family and the therapist.
Whitaker’s freewheeling, intuitive approach sought to unmask pretense and create new meaning while liberating family members to be themselves.  Whitaker did not propose a set of methods; rather, it is the personal involvement of the therapist with a family that makes a difference.  When techniques are employed, they arise from the therapist’s intuitive and spontaneous reactions to the present situation and are designed to increase clients’ awareness of their inner potential and to open channels of family interaction.
Structural-Strategic Family Therapy:  The origins of structural family therapy can be traced to the early 1960s when Salvador Minuchin was conducting therapy, training, and research with delinquent boys from poor families at the Wiltwyck School in New York.  Minuchin’s central idea was than an individual’s symptoms are best understood from the vantage point of interactional patterns within a family and that structural changes must occur in a family before an individual’s symptoms can be reduced or eliminated.  The goals of structural family therapy are twofold:  (1) reduce symptoms of dysfunction and (2) bring about structural change within the systems by modifying the family’s transactional rules and developing more appropriate boundaries.  Both structural family therapy and strategic models seek to reorganize dysfunctional or problematic structures in the families; boundary setting, unbalancing, reframing, ordeals, and enactments all became part of the family therapeutic process.  Neither approach deals much with exploration or interpretation of the past.  Rather, it is the job of structural-strategies therapists to join with the family, to block stereotyped interactional patterns, to reorganize family hierarchies or subsystems, and to facilitate the development of more flexible or useful transactions.
Recent Innovations:  In the last decade, feminism, multiculturalism, and postmodern social constructionism have all entered the family therapy field.  These models are more collaborative, treating clients – individuals, couples, or families – as experts in their own lives.
Tom Anderson of Norway helped to give birth to the reflecting team, an approach that has quickly gained wide acceptance in family therapy, and in teaching and supervision of trainees as well.  When the reflecting team responds to the family, the team members are expected to let their imaginations flow, subject only to a respect for the family.  Reflections are most often offered as tentative ideas directly connected to the verbal and nonverbal information in the preceding dialogue.  The team remains positive in reflecting, reframing stories and parts of stories, looking for alternative stories, and wondering out loud about the possibility and impact of implementing these alternative stories.  The family and the initial interviewer listen, and the interviewer monitors family reactions, looking for ways in which the reflecting team may be expanding the family’s ideas.  The session ends with the initial interviewer seeking the family members’ reactions to what they have experienced.
The original six metaframeworks are internal family systems; sequences; organization; developmental; multicultural; and gender.  To these have been added teleological and process metaframeworks.  Any or all of these eight lenses may have meaningful applications with a given couple or family.  Furthermore, use of any particular lens influences and is influenced by the other seven perspectives, a feature common to all systems theories.  The value of this approach is that it allows the therapist to draw on multiple perspectives rather than being locked into a single viewpoint.  The lenses can be used for assessment as well as to tailor therapeutic interventions to the specific needs of the family.  These eight lenses provide a foundation for integrating the various models of family systems therapy.
The Individual’s Internal Family System:
Multiple family theorists and practitioners have made contributions to a lens that views the individual as an organismic system, complete with structure, organization, and subsystems.  An individual is made up of many parts, or dimensions, to their personality.  Some of these facets of personality are self-enhancing, and some are self-destructive.  Some of these aspects may be physical, cognitive, emotional, social or spiritual.  Some are used more than others.  These parts emanate from our social interactions and developmental experiences.  They are often evaluative in nature, declaring something about who we are and what has meaning to us.  It is when parts become polarized and extreme – or needed parts seem inaccessible – that individuals experience internal conflict.  The entity, known as the self or the person, is the whole of the individual system – that which operates the rest of the parts.
The Teleological Lens:
Teleology refers to the study of final causes, goals, endpoints, and purposes.  The teleological lens enables the family therapist to develop an understanding of what motivates individual behavior, the systemic purpose of symptoms, the goals of triangulation, and the uses of patterned interactions and routines.  
Both individuals and families-as-a-whole act purposively.  Purposeful actions promote growth and development when they are characterized by reasonable risk, courage, confidence, self-esteem, energy, optimism, hope, and sequences of experience that open even wider possibilities for experience.  Alternatively, actions and interactions characterized by retreat, fear, and protection tend to constrain growth and development.
In Adlerian family therapy, goal orientation and recognition are central for understanding motivations of parents and children – and for unlocking mistaken interactions.  Dreikurs developed a systematic approach to goal recognition based on (a) descriptions of the child’s misbehavior, (b) the parents’ reactions to the misbehavior, and (c) the child’s reaction to the parents’ attempts at discipline.
The teleological lens can be used in any model that includes assessment and the generation of meaning as well as for interventions such as reframing, or putting what is known into a new, more useful perspective.  Family therapists often reframe difficult behaviors by noting the motivation or personal intentions behind the behavior.  Reframing begins by asking these kinds of questions:
• What purposes does this symptom, interaction, or process serve?
• How does the individual’s behavior protect the self?
• What are the social consequences of an action or interaction?
• How are the goals of family members at cross-purposes with each other?
• Are the goals of the family at odds with the goals of therapy?
Sequences:  Tracking Patterns of Interaction:
One of the defining aspects of family life is that it is ordered, and family members tend to interact in sequences that, over time, are repeated in multiple forms.  Breunlin and his associates (1997) refer to these patterns as embedded sequences and they occur at multiple levels within the sequencing metaframework.
Level 1 sequences occur between two or more family members who are face-to-face.  
Level 2 sequences support the functioning of the family and become accepted as routines.  In this sequence, individual roles support a smooth process for the whole system.  If any part of this routine stops or breaks down, the whole system must adjust.  
Level 3 sequences have to do with the ebbs and flows of life.  These much longer sequences often account for family adjustments to outside forces or developmental changes.  
Level 4 sequences are transgenerational.  They include sequences that reflect larger system values and rules about culture or gender roles.  These sequences are passed from one generation to the next and are intended to provide a sense of continuity to life.
Adaptive sequences require leadership that is balanced, fair, and cooperative.  Maladaptive sequences occur when rules are rigid and inflexible, when parts are polarized, and when change is resisted.  Family therapy is often about developing more useful sequences at any or all of these four levels.
The Organization Lens:
Individuals and families have some organizing process that holds everything together and provides a sense of unity.  In family systems, organization is manifest in family rules, routines, rituals, and expected roles.  Collaboration is found in mutual or egalitarian relationships between couples, and the function of leadership in the family is to organize the system in clear, useful ways.  Balanced family leadership requires the ability to be firm, but friendly, and to set developmentally appropriate limits while remaining fair, flexible, and encouraging.  In balanced families, individuality and connection to the family are both significant:  both fit generational, cultural, and developmental needs.
The Developmental Lens:

The “family life cycle” is a developmental framework that is focused on the nuclear family.  The family life cycle focuses on six significant transitions:
1. A single, young adult leaves home to live a more or less independent life.
2. Individuals marry or become a couple to build a life together.
3. The couple has children and starts a family.
4. The children become adolescents.
5. The parents launch their children into the world and prepare to live a life without children.
6. The family reaches its later years where children may have to care for parents as well as their own children, and the parents prepare for the end of their lives.
The first presentations of the family life cycle were focused almost entirely on a two-parent, Caucasian, nuclear family, but today there are developmental models for single-parent families; remarried, blended, or stepfamilies; cross-generational, extended families; lesbian, gay, and bisexual families; families from diverse cultures; poverty and the family life cycle; and the effects of gender (and roles) in the family life cycle.  In family therapy, growth and development are desired processes.  Our belief in development and evolution is optimistic and hopeful.  Family therapists address the needs of individuals while simultaneously considering the needs of relationships, the family, and larger systems.  In assessing different levels, family therapists look for constraints and seek to remove them so that natural growth and transitions become possible once again.
The Multicultural Lens:
A multicultural lens challenges dominant culture and introduces diversity and complexity into our understanding of the human condition.  This lens reframes dominant culture as simply one of many.  It seeks not tolerance but an appreciation and valuing of diversity.  
Ten areas of assessment assist family therapists in bringing a multicultural perspective to their work:
• Membership as an immigrant in a dominant society
• Level of economic privilege or poverty
• Level of education and process of learning
• Ethnicity
• Religion
• Gender
• Age
• Race, discrimination, and oppression
• Minority versus majority status
• Regional background
The Gender Lens:
Family therapists have increasingly accepted an advocacy stance as pat of their therapy.  Therapists can no longer ignore their personal influence and their responsibility to challenge unequal status and treatment of women.  Power positions, like hierarchy, enmeshment, and unbalancing – catchwords that have been associated with structural-strategic approaches to families for years – are slowly being replaced with ideas about leadership, connection, conversation, and collaboration.
The Process Lens:
Process is also about our movement through significant events in life.  Clarity of process tells us where we are and delineates where we are likely to go.  It allows the therapist and the family to examine where they are in the flow of life, the process of change, and the experience of therapy.  When essential routines are interfered with, the result is a disruption that throws a system out of balance.  In the face of disruption, families may initially seek to retreat, but they generally fall into a state of chaos.  Because chaos is experienced as crisis, family members often want to make huge decisions even though everything seems out of balance.  Therapists immediately become one of the family’s external resources with a primary responsibility to help individuals reconnect with their internal resources and strengths, which are often not recognized.
Somewhat paradoxically, change is facilitated by staying present and by not trying to change anything at all.  Staying with feelings and present experience, finding ways to become grounded and rebalanced, and reconnecting with useful internal parts and external resources help people to develop new possibilities.
This is the “blueprint for therapy” using a family systems approach.  There are four general movements, each with different tasks:  forming a relationship, conducting an assessment, hypothesizing and sharing meaning, and facilitating change.  In rare instances, these four movements might occur within a single session:  in most cases, however, each movement requires multiple sessions.
Forming a Relationship:  Therapists begin to form a relationship with clients from the moment of first contact.  In most cases, we believe therapists should make their own appointments, answer initial questions clients may have, and give clients a sense of what to expect when they come.  This is also a time when counselors can let families know their position on whether all members should be present.  Some family therapists will work with an of those members of the family who wish to come; others will only see the family if everyone is a part of the therapy session.
Conducting an Assessment:  There are many forms of assessment procedures in family therapy.  Examples include genograms, circular questioning, or even formal tests and rating scales.  Focusing on the meta-issues presented in content is one way to begin to select lenses that will provide meaning for the therapist and the family.  The therapist might choose to select any one of these lenses for further inquiry:  Internal Family Systems; Sequences; Gender Lens; Developmental Lens.
Hypothesizing and Sharing Meaning:  Families are invited into respectful, essentially collaborative dialogues in therapeutic work.  The different perspectives discovered in this work tend to coalesce into working hypotheses, and sharing these ideas provides the family with a window into the heart and mind of the therapist as well as themselves.  Sharing hypotheses almost immediately invites and invokes feedback from various family members.  This feedback allows the therapist and the family to develop a good fit with each other.  The therapist may seek permission for their disclosure:
1. I have an idea I would like to share with you.  Would you be willing to hear it?
2. Could it be that . . . 
Facilitating Change:  Two of the most common forms for facilitation of change are enactments and assignment of tasks.  Both of these processes work best when the family co-constructs them with the therapist.  Knowing the goals and purposes for our behaviors, feelings, and interactions tends to give us choices about their use.  Understanding the patterns we enact in face-to-face relationships, the ebbs and flows of life, or across generations provides multiple avenues for challenging patterns and the enactment of new possibilities. 
Dr. Rebecca Curtis


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