Lesson 36

FAMILY AND COUPLES FAMILY AND COUPLES THERAPYTHERAPY

Lecture 36Lecture 36

FAMILY THERAPYFAMILY THERAPY

Family therapy is a form of Family therapy is a form of psychotherapypsychotherapy that that involves all the members of a nuclear or involves all the members of a nuclear or extended family. extended family.

It may be conducted by a pair of therapists—It may be conducted by a pair of therapists—often a man and a woman—to treat gender-often a man and a woman—to treat gender-related issues or serve as role models for family related issues or serve as role models for family members. members.

Although some types of family therapy are Although some types of family therapy are based on behavioral or psychodynamic based on behavioral or psychodynamic principles, the most widespread form is based principles, the most widespread form is based on family systems theory, an approach that on family systems theory, an approach that regards the entire family as the unit of regards the entire family as the unit of treatment, and emphasizes such factors as treatment, and emphasizes such factors as relationships and communication patterns relationships and communication patterns rather than traits or symptoms in individual rather than traits or symptoms in individual members members

PURPOSE:-PURPOSE:- The purpose of family therapy is to identify and The purpose of family therapy is to identify and

treat family problems that cause dysfunction.treat family problems that cause dysfunction.

Family therapy is often recommended when:Family therapy is often recommended when: A family member has schizophrenia or suffers from A family member has schizophrenia or suffers from

another severe another severe psychosis.psychosis. Problems cross generational boundaries.Problems cross generational boundaries. Families deviate from social norms (unmarried Families deviate from social norms (unmarried

parents, gay couples rearing children, etc.).parents, gay couples rearing children, etc.). Members come from mixed racial, cultural, or religious Members come from mixed racial, cultural, or religious

backgrounds. backgrounds. One member is being scapegoated, or their treatment One member is being scapegoated, or their treatment

in individual therapy is being undermined. in individual therapy is being undermined. The identified patient's problems seem inextricably The identified patient's problems seem inextricably

tied to problems with other family members.tied to problems with other family members. A blended (i.e. step) family is having adjustment A blended (i.e. step) family is having adjustment

difficulties. difficulties.

PRECAUTIONS:-PRECAUTIONS:- Before family therapy begins, family members are Before family therapy begins, family members are

required to undergo a comprehensive clinical required to undergo a comprehensive clinical evaluation (interview) that includes questions of a evaluation (interview) that includes questions of a personal and sensitive nature.personal and sensitive nature.

Honest communication between the family members Honest communication between the family members and the therapist is essential; people who are not and the therapist is essential; people who are not willing to discuss and change behaviors may not willing to discuss and change behaviors may not benefit from therapy.benefit from therapy.

Families that may not be considered suitable Families that may not be considered suitable candidates for family therapy include those in which:candidates for family therapy include those in which:

One or both parents is psychotic or have been One or both parents is psychotic or have been diagnosed with antisocial or paranoid personality diagnosed with antisocial or paranoid personality disorder. disorder.

Cultural or religious values are opposed to, or Cultural or religious values are opposed to, or suspicious of, psychotherapy.suspicious of, psychotherapy.

Some family members cannot participate in Some family members cannot participate in treatment sessions because of illness or other treatment sessions because of illness or other physical limitations. physical limitations.

Individuals have very rigid personality Individuals have very rigid personality structures and might be at risk for an emotional structures and might be at risk for an emotional or psychological crisis. or psychological crisis.

Members cannot or will not be able to meet Members cannot or will not be able to meet regularly for treatment. regularly for treatment.

The family is unstable or on the verge of break-The family is unstable or on the verge of break-up. up.

Intensive family therapy may be difficult for Intensive family therapy may be difficult for psychotic family members.psychotic family members.

DESCRIPTIONDESCRIPTION:: It began shortly after World War II, when doctors who It began shortly after World War II, when doctors who

were treating schizophrenic patients noticed that the were treating schizophrenic patients noticed that the patients' families communicated in disturbed ways. patients' families communicated in disturbed ways.

These observations led to considering a family as an These observations led to considering a family as an organism (or system) with its own internal rules, organism (or system) with its own internal rules, patterns of functioning, and tendency to resist change.patterns of functioning, and tendency to resist change.

When the therapists began to treat the families as When the therapists began to treat the families as whole units instead of focusing solely on the whole units instead of focusing solely on the hospitalized member, they found that in many cases hospitalized member, they found that in many cases the schizophrenic family member improve. the schizophrenic family member improve.

Family therapy is becoming an increasingly common Family therapy is becoming an increasingly common form of treatment as changes in American society are form of treatment as changes in American society are reflected in family structures; it is also helpful when a reflected in family structures; it is also helpful when a child or other family member develops a serious child or other family member develops a serious physical illness. physical illness.

Family therapy tends to be short term, usually several Family therapy tends to be short term, usually several months in length, aimed at resolving specific problems months in length, aimed at resolving specific problems such as eating disorders, difficulties with school, or such as eating disorders, difficulties with school, or adjustments to bereavement or geographical adjustments to bereavement or geographical relocation. relocation.

It is not normally used for long-term or intensive It is not normally used for long-term or intensive restructuring of severely dysfunctional families. restructuring of severely dysfunctional families.

In therapy sessions, all members of the family and In therapy sessions, all members of the family and both therapists are present. both therapists are present.

The therapists try to analyze communication and The therapists try to analyze communication and interaction between all members of the family. interaction between all members of the family.

Therapists who work as a team also model new Therapists who work as a team also model new behaviors through their interactions with each other. behaviors through their interactions with each other.

Family therapy is based on systems theory.Family therapy is based on systems theory. Problems are treated by changing the way the Problems are treated by changing the way the

system works rather than trying to "fix" a system works rather than trying to "fix" a specific member. specific member.

Family systems theory is based on several Family systems theory is based on several major concepts:major concepts:

The identified patient:-The identified patient:-The identified patient The identified patient (IP) is the family member with the symptom that (IP) is the family member with the symptom that has brought the family into treatment.has brought the family into treatment.

Homeostasis:-Homeostasis:-This concept presumes that the This concept presumes that the family system seeks to maintain its customary family system seeks to maintain its customary organization and functioning over time.organization and functioning over time.

The extended family field:-The extended family field:-The extended family field The extended family field is the nuclear family plus the network of grandparents is the nuclear family plus the network of grandparents and other members of the extended family.and other members of the extended family.

Differentiation:-Differentiation:-Differentiation refers to each family Differentiation refers to each family member's ability to maintain his or her own sense of member's ability to maintain his or her own sense of self while remaining emotionally connected to the self while remaining emotionally connected to the family; this is the mark of a healthy family.family; this is the mark of a healthy family.

Triangular relationships:-Triangular relationships:-Family systems theory Family systems theory maintains that emotional difficulties in families are maintains that emotional difficulties in families are usually triangular—whenever any two persons have usually triangular—whenever any two persons have problems with each other, they will "triangle in" a third problems with each other, they will "triangle in" a third member to stabilize their own relationship.member to stabilize their own relationship.

POSSIBLE RISKSPOSSIBLE RISKS There are no major risks involved in receiving family There are no major risks involved in receiving family

therapy, especially if family members seek the therapy therapy, especially if family members seek the therapy with honesty, openness, and a willingness to change. with honesty, openness, and a willingness to change. Changes that result from the therapy may be seen by Changes that result from the therapy may be seen by some as "risks"—the possible unsettling of rigid some as "risks"—the possible unsettling of rigid personality defenses in individuals, or the unsettling of personality defenses in individuals, or the unsettling of couple relationships that had been fragile before the couple relationships that had been fragile before the beginning of therapy, for example. beginning of therapy, for example.

NORMAL RESULTSNORMAL RESULTS The goal of therapy is the identification and resolution The goal of therapy is the identification and resolution

of the problem that is causing the family's unhealthy of the problem that is causing the family's unhealthy interactions. Results vary, but in good circumstances interactions. Results vary, but in good circumstances they include greater insight, increased differentiation they include greater insight, increased differentiation of individual family members, improved of individual family members, improved communication within the family, and loosening of communication within the family, and loosening of previously automatic behavior patterns. previously automatic behavior patterns.

VARIETIES OF FAMILY VARIETIES OF FAMILY THERAPYTHERAPY

CONJOINT FAMILY THERAPYCONJOINT FAMILY THERAPY: -: -

In conjoint family therapy, In conjoint family therapy, the entire-family is seen at the the entire-family is seen at the same time by one therapist. same time by one therapist.

In some varieties of this approach, the therapist plays In some varieties of this approach, the therapist plays a, rather passive, nondirective role. a, rather passive, nondirective role.

In other varieties, the therapist is an active force, In other varieties, the therapist is an active force, directing the conversation, assigning tasks to various directing the conversation, assigning tasks to various family members, imparting, direct instruction regarding family members, imparting, direct instruction regarding human relationshuman relations,, and, so on. and, so on.

Satir regarded the family therapist as a resource Satir regarded the family therapist as a resource perspersoon who observes the family process in action and n who observes the family process in action and then becomes a modethen becomes a modell of communication to the family of communication to the family through clear, crisp communication. through clear, crisp communication.

Thus, Satir viewed the therapist as a--teacher, a Thus, Satir viewed the therapist as a--teacher, a resource person, and a communicator. resource person, and a communicator.

Concurrent Family Therapy: -Concurrent Family Therapy: - In In concurrent family therapy, concurrent family therapy, one therapist sees all one therapist sees all

family members, but in individual sessions.family members, but in individual sessions.

In some instances, the therapist may conduct In some instances, the therapist may conduct traditional psychotherapy with the principal patient but traditional psychotherapy with the principal patient but also occasionally see other members of the family. also occasionally see other members of the family.

As a matter of fact, it is perhaps unfortunate that the As a matter of fact, it is perhaps unfortunate that the last variation is not used more often as a part of last variation is not used more often as a part of traditional psychotherapy.traditional psychotherapy.

The use of such arrangements should facilitate the The use of such arrangements should facilitate the therapeutic process.therapeutic process.

Collaborative Family TherapyCollaborative Family Therapy::

In In collaborative collaborative family family therapy, therapy, each family member each family member sees a different therapist. sees a different therapist.

The therapists then get together to discuss their The therapists then get together to discuss their patients and the family as a whole. patients and the family as a whole.

The use of this approach with child patients was one The use of this approach with child patients was one of the factors that stimulated the early growth of family of the factors that stimulated the early growth of family therapy. therapy.

In a variation of this general approach, co-therapists In a variation of this general approach, co-therapists are sometimes assigned to work with the same family. are sometimes assigned to work with the same family.

Behavioral family therapyBehavioral family therapy: : A process of inducing family members to dispense the A process of inducing family members to dispense the

appropriate reinforcements to one another for the appropriate reinforcements to one another for the desired behaviors. desired behaviors.

Some therapists even have family members use Some therapists even have family members use tokens for this purpose. tokens for this purpose.

it is not surprising that this approach has found its way it is not surprising that this approach has found its way into the family therapy enterprise. into the family therapy enterprise.

Similar to cognitive-behavioral therapy for the Similar to cognitive-behavioral therapy for the individual, the family "version" involves teaching individual, the family "version" involves teaching individual family members to self-monitor problematic individual family members to self-monitor problematic behaviors and patterns of thinking, to develop new behaviors and patterns of thinking, to develop new skills , and to challenge interpretations of family events skills , and to challenge interpretations of family events and reframe these interpretation if necessary.and reframe these interpretation if necessary.

COUPLES THERAPYCOUPLES THERAPY

The focus of couples therapy is to identify the presence The focus of couples therapy is to identify the presence of dissatisfaction and distress in the relationship, and of dissatisfaction and distress in the relationship, and to devise and implement a treatment plan. to devise and implement a treatment plan.

The objectives of treatment are to improve or alleviate The objectives of treatment are to improve or alleviate the symptoms and restore the relationship to a the symptoms and restore the relationship to a healthier level of functioning. healthier level of functioning.

Also called marital therapy or marriage counseling.Also called marital therapy or marriage counseling.

It is designed to help intimate partners improve their It is designed to help intimate partners improve their relationship Couples therapy is a form of psychological relationship Couples therapy is a form of psychological therapy used to treat relationship distress for both therapy used to treat relationship distress for both individuals and couples.individuals and couples.

PURPOSEPURPOSE The purpose of couples therapy is to restore a better The purpose of couples therapy is to restore a better

level of functioning in couples who experience level of functioning in couples who experience relationship distress. relationship distress.

The reasons for distress can include poor The reasons for distress can include poor communication skills, incompatibility, or a broad communication skills, incompatibility, or a broad spectrum of psychological disorders that include spectrum of psychological disorders that include domestic violence, alcoholism, depression, anxiety, domestic violence, alcoholism, depression, anxiety, and and schizophreniaschizophrenia. .

The focus is to identify the presence of dissatisfaction The focus is to identify the presence of dissatisfaction and distress in the relationship, and to devise and and distress in the relationship, and to devise and implement a treatment plan with objectives designed implement a treatment plan with objectives designed to improve or alleviate the presenting symptoms and to improve or alleviate the presenting symptoms and restore the relationship to a better and healthier level restore the relationship to a better and healthier level of functioning. of functioning.

PRECAUTIONSPRECAUTIONS

Couples who seek treatment should consult for Couples who seek treatment should consult for services from a mental health practitioner who services from a mental health practitioner who specializes in this area.specializes in this area.

Patients should be advised that honesty, Patients should be advised that honesty, providing all necessary information, providing all necessary information, cooperation, keeping appointments on time, cooperation, keeping appointments on time, and a sincere desire for change and and a sincere desire for change and improvement are all imperative to increase the improvement are all imperative to increase the chance of successful outcome. chance of successful outcome.

Additionally, a willingness to work "towards" Additionally, a willingness to work "towards" and "with" the process of treatment is essential. and "with" the process of treatment is essential.

DESCRIPTIONDESCRIPTION Couples therapy sessions differ according to Couples therapy sessions differ according to

the chosen model, or philosophy behind the the chosen model, or philosophy behind the therapy. therapy.

There are several models for treating couples There are several models for treating couples with relationship difficulties. These commonly with relationship difficulties. These commonly utilized strategies include: utilized strategies include:

• Psychoanalytic couples therapy, Psychoanalytic couples therapy, • Object relations couple therapy, Object relations couple therapy, • Ego analytical couples therapy, Ego analytical couples therapy, • Behavioral couples therapy, Behavioral couples therapy, • Integrative behavioral couples therapy, andIntegrative behavioral couples therapy, and• Cognitive behavioral couples therapy. Cognitive behavioral couples therapy.

PSYCHOANALYTICAL COUPLES THERAPYPSYCHOANALYTICAL COUPLES THERAPY Psychoanalytic therapy attempts to uncover Psychoanalytic therapy attempts to uncover

unresolved childhood conflicts with parental figures.unresolved childhood conflicts with parental figures.

It tends to develop an understanding of interpersonal It tends to develop an understanding of interpersonal interactions (at present) in connection with early interactions (at present) in connection with early development. development.

The essential core of this model deals with the The essential core of this model deals with the process of separation and individuation from mother-process of separation and individuation from mother-child interactions during childhood. child interactions during childhood.

A critical part of this model is introjection. A critical part of this model is introjection.

The psychoanalytic approach analyzes marital The psychoanalytic approach analyzes marital relations and mate selection as originating from relations and mate selection as originating from parent-child relationship during developmental stages parent-child relationship during developmental stages of the child. of the child.

OBJECT RELATIONS COUPLE THERAPYOBJECT RELATIONS COUPLE THERAPY

The object relations model creates an environment of The object relations model creates an environment of neutrality and impartiality to understand the distortions neutrality and impartiality to understand the distortions and intra-psychic (internalized) conflicts that each and intra-psychic (internalized) conflicts that each partner contributes to the relationship in the form of partner contributes to the relationship in the form of dysfunctional behaviors. dysfunctional behaviors.

This model proposes that there is a complementary This model proposes that there is a complementary personality fit between couples that is unconscious personality fit between couples that is unconscious and fulfills certain needs. and fulfills certain needs.

This model supports the thought that a "mothering This model supports the thought that a "mothering figure" is the central motivation for selection and figure" is the central motivation for selection and attachment of a mate. attachment of a mate.

Choosing a "mothering" figure induces further Choosing a "mothering" figure induces further repression This repression causes relationship repression This repression causes relationship difficulties. difficulties.

EGO ANALYTICAL COUPLES THERAPYEGO ANALYTICAL COUPLES THERAPY Ego analytical approaches utilize methods to foster Ego analytical approaches utilize methods to foster

the ability to communicate important feelings in the the ability to communicate important feelings in the couple's relationship. couple's relationship.

This model proposes that dysfunction originates from This model proposes that dysfunction originates from the patient's incapabilities to recognize intolerance the patient's incapabilities to recognize intolerance and invalidation of sensitivities and problems in a and invalidation of sensitivities and problems in a relationship. relationship.

There are two major categories of problems: There are two major categories of problems: 1.1. Dysfunction brought into the relationship from early Dysfunction brought into the relationship from early

childhood trauma and experiences. childhood trauma and experiences. 2.2. The patient's reaction to difficulties and a sense of The patient's reaction to difficulties and a sense of

unentitlement . unentitlement .

A patient's shame and guilt are major factors A patient's shame and guilt are major factors precipitating the thoughts of unentitlement. precipitating the thoughts of unentitlement.

BEHAVIORAL MARITAL THERAPYBEHAVIORAL MARITAL THERAPY

Behavioral marital therapists tend to improve Behavioral marital therapists tend to improve relationships between a couple by increasing relationships between a couple by increasing positive exchanges and decreasing the positive exchanges and decreasing the frequency of negative and punishing frequency of negative and punishing interactions. interactions.

This model focuses on the influence that This model focuses on the influence that environment has in creating and maintaining environment has in creating and maintaining relationship.relationship.

The amount of rewards (positive re-inforcers) The amount of rewards (positive re-inforcers) received in relation to the amount of aversive received in relation to the amount of aversive behavior is linked to an individual's sense of behavior is linked to an individual's sense of relationship dissatisfaction. relationship dissatisfaction.

COGNITIVE BEHAVIORAL COUPLES COGNITIVE BEHAVIORAL COUPLES THERAPYTHERAPY

The cognitive approach therapist educates and The cognitive approach therapist educates and increases awareness concerning perceptions, increases awareness concerning perceptions, assumptions, attributions or standards of interaction assumptions, attributions or standards of interaction between the couple. between the couple.

The central theme for understanding marital discourse The central theme for understanding marital discourse using cognitive behavioral therapy is based on the using cognitive behavioral therapy is based on the behavioral marital therapy model. behavioral marital therapy model.

A couple's emotional and behavioral dysfunctions are A couple's emotional and behavioral dysfunctions are related to inappropriate information processing, and related to inappropriate information processing, and negative cognitive appraisals. negative cognitive appraisals.

This models attempts to discover the negative types of This models attempts to discover the negative types of thinking that drive negative behaviors that cause thinking that drive negative behaviors that cause relationship distress relationship distress

Follow UpFollow Up Treatment usually takes several months or longer. Treatment usually takes several months or longer.

Once the couple has developed adequate skills and Once the couple has developed adequate skills and has displayed an improved level of functioning that is has displayed an improved level of functioning that is satisfactory to both, then treatment can be terminated.satisfactory to both, then treatment can be terminated.

An awareness of relapse prevention behaviors and An awareness of relapse prevention behaviors and relapsing behaviors is important. relapsing behaviors is important.

Patients are encouraged to return to treatment if Patients are encouraged to return to treatment if relapse symptoms appear. relapse symptoms appear.

Follow-up visits and long-term psychological therapy Follow-up visits and long-term psychological therapy can be arranged between parties if this is mutually can be arranged between parties if this is mutually decided as necessary decided as necessary

POSITIVE RESULTSPOSITIVE RESULTS A normal progression of couple’s therapy is relief from A normal progression of couple’s therapy is relief from

symptomatic behaviors that cause marital discourse, symptomatic behaviors that cause marital discourse, distress, and difficulties. distress, and difficulties.

The couple is restored to healthier interactions and The couple is restored to healthier interactions and behaviors are adjusted to produce a happier balance behaviors are adjusted to produce a happier balance of mutually appropriate interactions. of mutually appropriate interactions.

Patients who are sincere and reasonable with a Patients who are sincere and reasonable with a willingness to change tend to produce better willingness to change tend to produce better outcomes. Patients usually develop skills and outcomes. Patients usually develop skills and increased awareness that promotes healthier increased awareness that promotes healthier relationship interactions.relationship interactions.

RISK FACTORSRISK FACTORS The major risk of couples therapy is lack of The major risk of couples therapy is lack of

improvement or return to dysfunctional behaviors.improvement or return to dysfunctional behaviors.

These tend not to occur unless there is a breakdown These tend not to occur unless there is a breakdown in skills learned and developed during treatment, or a in skills learned and developed during treatment, or a person is resistant to long-term change. person is resistant to long-term change.

LimitationsLimitations There are no known abnormal results from couples There are no known abnormal results from couples

therapy. therapy. At worst, patients do not get better.At worst, patients do not get better. The problems are not worsened if treatment is The problems are not worsened if treatment is

provided by a trained mental health practitioner in this provided by a trained mental health practitioner in this specialty. specialty.