FAMILY THERAPY - DEAN AMORY

AN
INTRODUCTION TO
FAMILY
THERAPY
Tags: Family Therapy - Practical Guide – Manual – Theory – Summary - Course – counselling – counsellor
Compiled by Dean Amory

Title: An Introduction to Family Therapy
Compiled by: Dean Amory
Dean_Amory@hotmail.com
Publisher: Edgard Adriaens, Belgium
eddyadriaens@yahoo.com
ISBN:
PUBLIC DOMAIN PUBLICATION
© Copyright 2013 Edgard Adriaens, Belgium, - All Rights Reserved.
This book has been compiled based on information that is freely accessible in the public domain on the internet.
Whenever you cite such information or reproduce it in any form, please credit the source or check with author
or editor.
If you are aware of a copyright ownership that I have not identified or credited, please contact me at:
Dean_Amory@hotmail.com
3

Cover Illustration:
Zirta - Ilustrador, Diseñador, Historietista
Beatriz Torres, 1981, Tampico, México.
He dibujado historias toda mi vida. Estudié la carrera de Diseño Gráfico, pero mi verdadera pasión son los
cómics. En 2001, mi amiga Shiaya y yo creamos HED: Hilando el Destino.
En 2006 propuse Oseano como tira cómica al diario La Razón de Tampico, donde lo publiqué diariamente hasta
2011.
Actualmente me desempeño como ilustradora freelance, y estoy trabajando en mi primera novela gráfica.
Contacto: beatriz@zirta.net
Zirta - Illustrator, designer, cartoonist
I've drawn stories all my life. I studied Graphic Design, but my real passion is comics.
In 2001, my friend Shiaya and I created HED: Spinning Destiny.
In 2006 I proposed the comic strip Oseano to the newspaper “La Razón de Tampico”, and published daily
until 2011.
Currently I am working as a freelance illustrator and I am working on my first graphic novel.
5

Preface
All information in this manual was collected for personal use from freely accessible sites on the internet, a lot of
it was found in the free encyclopaedia Wikipedia.
The same applies to all pictures used, which I downloaded from public domain sites, with exception for the
cover picture “la familia Dupont”, which was kindly made available to this purpose by its creator, Zirta (Beatriz
Torres, Mexico).
Since I feel many people will benefit and appreciate being allowed to get easy access to this kind of information
ordered in short, easily accessible chapters, I decided to make this compilation work available for free to
everybody as a download file. A printed copy of the manual can be purchased at http://www.lulu.com
(http://www.lulu.com/shop/various-authors/practical-manual-of-family-therapy/paperback/product-
15478201.html)
Should any of the authors of the borrowed texts feel that the present manual is not compatible with the way in
which they planned to make their work available to the public, then I hereby invite them to contact me at
Dean_Amory@hotmail.com and let me know which part of the manual should be adapted or replaced by
information from other sources.
7

Family Therapy – Contents
Cover Illustration:...................................................................................................................................5
Zirta - Ilustrador, Diseñador, Historietista ........................................................................................5
Preface......................................................................................................................................................7
Family Therapy – Contents....................................................................................................................8
Family Therapy – Background Information ......................................................................................23
History of Marital Therapy .................................................................................................................24
Phase I - 1930 to 1963 - Atheoretical...........................................................................................24
Phase II - 1931 to 1966 - Psychoanalytic Experimentation ..........................................................24
Phase III - 1963 to 1985 - Family Therapy Incorporates .............................................................24
Phase IV - 1986 to now - Refining and Integrating .....................................................................24
History and theoretical frameworks ....................................................................................................25
Techniques ..........................................................................................................................................27
Publications .........................................................................................................................................28
Licensing and degrees .........................................................................................................................28
Values and ethics in family therapy ....................................................................................................28
Founders and key influences...............................................................................................................29
Principal Leaders in the Field: ............................................................................................................29
Salvador Minuchin ..........................................................................................................................30
Jay Haley.........................................................................................................................................30
Murray Bowen ................................................................................................................................31
Nathan Ackerman............................................................................................................................31
Virginia Satir...................................................................................................................................32
Ivan Boszmormenyi-Nagy ..............................................................................................................32
John Elderkin Bell...........................................................................................................................33
Philip Guerin ...................................................................................................................................33
Don Jackson ....................................................................................................................................33
Carl Whitaker ..................................................................................................................................34
Betty Carter .....................................................................................................................................34
Michael White.................................................................................................................................35
Models and Schools ............................................................................................................................36
Some contemporary family therapies: ............................................................................................36
Structural Family Therapy (Minuchin, 1974, Colapinto, 1991) .....................................................36
Conjoint Family Therapy (Satir, 1967)...........................................................................................36
Contextual Therapy (Boszormenyi-Nagy, 1991)............................................................................36
Strategic Therapy (Madanes, 1981) ................................................................................................36
Brief Therapy ..................................................................................................................................37
Milan Systemic Therapy (Boscolo et al, 1987)...............................................................................37
Narrative Therapy (Freedman, Combs, 1996) ................................................................................37
Academic resources ............................................................................................................................37
Professional Organizations..................................................................................................................37
Useful Internet links............................................................................................................................38
Wikipedia links ...............................................................................................................................38
8

External links ..................................................................................................................................38
Brief Strategic Family Therapy ...........................................................................................................39
Description ..........................................................................................................................................39
Program background ...........................................................................................................................39
Indicated..............................................................................................................................................39
Content focus ......................................................................................................................................39
Intervention by domain .......................................................................................................................40
Parents as a primary target population:...........................................................................................40
Individual: .......................................................................................................................................40
Family : ...........................................................................................................................................40
Peer :................................................................................................................................................40
Key program approaches.....................................................................................................................40
Parent-child interaction: ..................................................................................................................40
Parent training: ................................................................................................................................40
Skill development: ..........................................................................................................................40
Techniques used ..............................................................................................................................40
Therapy ...............................................................................................................................................40
How it works...................................................................................................................................40
There are four important BSFT steps:.............................................................................................41
Barriers and problems .....................................................................................................................41
Brief Strategic Family Therapy for Adolescent Drug Abuse............................................................42
Foreword .............................................................................................................................................42
Chapter 1 - Brief Strategic Family Therapy: An Overview................................................................43
BSFT is based on three basic principles. ........................................................................................43
Why Brief Strategic Family Therapy? ............................................................................................44
What Are the Goals of Brief Strategic Family Therapy?................................................................44
What Are the Most Common Problems Facing the Family of a Drug-Abusing Adolescent?........44
The Family Profile of a Drug-Abusing Adolescent ........................................................................45
The Behavioral Profile of a Drug-Abusing Adolescent..................................................................45
Negativity in the Family..................................................................................................................45
What Is Not the Focus of Brief Strategic Family Therapy?............................................................46
This Manual ....................................................................................................................................46
Chapter 2 - Basic Concepts of Brief Strategic Family Therapy..........................................................47
Context ............................................................................................................................................47
Family as Context ...........................................................................................................................47
Peers as Context ..............................................................................................................................47
Neighborhood as Context................................................................................................................47
Culture as Context...........................................................................................................................48
Counseling as Context.....................................................................................................................48
Systems ...........................................................................................................................................48
A Whole Organism .........................................................................................................................48
Family Systemic Influences ............................................................................................................48
The Principle of Complementarity..................................................................................................49
Structure: Patterns of Family Interaction ........................................................................................49
9

Strategy: The Three Ps of Effective Strategy..................................................................................50
Content Versus Process: A Critical Distinction ..............................................................................51
Chapter 3 - Diagnosing Family System Problems ..............................................................................52
Leadership .......................................................................................................................................52
Subsystem Organization..................................................................................................................52
Subsystem Membership ..................................................................................................................52
Triangulation ...................................................................................................................................53
Communication Flow......................................................................................................................53
Resonance .......................................................................................................................................53
Enmeshment and Disengagement ...................................................................................................53
Resonance and Culture....................................................................................................................54
Enmeshment (high resonance) and Disengagement (low resonance).............................................54
Developmental Stages.....................................................................................................................54
Assessing Appropriate Developmental Functioning.......................................................................55
Common Problems in Assessing Appropriateness of Developmental Stage..................................55
Life Context ....................................................................................................................................56
Antisocial Peers...............................................................................................................................56
Parent Support Systems and Social Resources ...............................................................................56
Juvenile Justice System...................................................................................................................56
Identified Patient .............................................................................................................................56
Conflict Resolution .........................................................................................................................57
A Caveat..........................................................................................................................................58
Chapter 4 - Orchestrating Change.......................................................................................................59
Establishing a Therapeutic Relationship.........................................................................................59
Joining.............................................................................................................................................59
A Cautionary Note: Family Secrets ................................................................................................60
Tracking ..........................................................................................................................................61
Encouraging the Family to Interact.................................................................................................61
Tracking Content and Process.........................................................................................................61
Mimesis ...........................................................................................................................................61
Building a Treatment Plan ..............................................................................................................62
Enactment: Identifying Maladaptive Interactions...........................................................................62
Family Crises as Enactments ..........................................................................................................62
A Cautionary Note: Adolescents Attending Therapy Sessions on Drugs.......................................63
From Diagnosis to Planning............................................................................................................63
Producing Change ...........................................................................................................................63
Seven Frequently Used Restructuring Techniques .........................................................................64
1. Working in the present ................................................................................................................64
2. Reframing: Systemic Cognitive Restructuring ...........................................................................64
Affect: Creating Opportunities for New Ways of Behaving...........................................................65
3. Reversals .....................................................................................................................................66
4. Working With Boundaries and Alliances ...................................................................................66
Behavioral Contracting as a Strategy for Setting Limits for Both Parent and Adolescent .............67
Boundaries Between the Family and the Outside World ................................................................67
5. Detriangulation............................................................................................................................68
Attempts by the Family to Triangulate the Counselor ....................................................................68
6. Opening Up Closed Systems.......................................................................................................69
7. Tasks ...........................................................................................................................................69
Central Role ....................................................................................................................................69
General Rule....................................................................................................................................69
Hope for the Best; Be Prepared for the Worst ................................................................................69
10

Chapter 5 - Engaging the Family Into Treatment ...............................................................................70
The Problem ....................................................................................................................................70
Dealing With Resistance to Engagement........................................................................................71
The Task of Coming to Treatment ..................................................................................................72
Joining.............................................................................................................................................72
Establishing a Therapeutic Alliance................................................................................................73
Diagnosing the Interactions That Keep the Family From Coming Into Treatment ........................73
Restructuring the Resistance ...........................................................................................................74
Types of Resistant Families ............................................................................................................74
Powerful Identified Patient .............................................................................................................74
Contact Person Protecting Structure ...............................................................................................75
Disengaged Parent...........................................................................................................................76
Families With Secrets .....................................................................................................................76
Chapter 6 - Clinical Research Supporting Brief Stategic Family Therapy.........................................77
Outpatient Brief Strategic Family Therapy Versus Outpatient Group Counseling ........................77
Conduct Disorder. ...........................................................................................................................78
Association With Antisocial Peers..................................................................................................78
One Person Brief Strategic Family Therapy ...................................................................................79
Brief Strategic Family Therapy Engagement..................................................................................79
The six levels of engagement effort ................................................................................................80
Efficacy of methods of engagement...............................................................................................80
References .......................................................................................................................................81
Solution focused brief therapy .............................................................................................................86
Contents...............................................................................................................................................86
Basic Principles:..................................................................................................................................86
Questions.............................................................................................................................................87
The miracle question .......................................................................................................................87
Scaling Questions............................................................................................................................88
Exception Seeking Questions..........................................................................................................88
Coping questions.............................................................................................................................88
Problem-free talk.............................................................................................................................89
Resources ............................................................................................................................................89
History of Solution Focused Brief Therapy ........................................................................................89
Solution-Focused counselling .............................................................................................................90
Solution-Focused consulting...............................................................................................................90
References ...........................................................................................................................................90
Brief (psycho-) therapy .........................................................................................................................91
Founding proponents of Brief Therapy...............................................................................................91
An Overview of Brief Therapy ...........................................................................................................93
The brief therapy solution-focused approach can be summed up in three stages,..........................93
Strategic Family Therapy.....................................................................................................................94
Haley Model........................................................................................................................................95
Behavior Problems ..............................................................................................................................95
Family Interaction ...............................................................................................................................95
Therapy ...............................................................................................................................................95
Who Does it Help? ..............................................................................................................................97
11

Bowen’s Strategic Family Therapy .....................................................................................................98
Contents...............................................................................................................................................98
Introduction .........................................................................................................................................98
The family system ...............................................................................................................................98
There are eight interlocking concepts in Dr. Bowen's theory:........................................................99
1) Differentiation of self:.............................................................................................................99
2) Triangles:.................................................................................................................................99
3) Nuclear family emotional system: ..........................................................................................99
4) Family projection process: ......................................................................................................99
5) Multigenerational transmission process:.................................................................................99
6) Emotional cut-off: ...................................................................................................................99
7) Sibling position: ......................................................................................................................99
8) Societal emotional process:.....................................................................................................99
1. Differentiation of Self ...............................................................................................100
2. Triangles....................................................................................................................103
3. The Nuclear Family Emotional Processes ................................................................105
4. The Family Projection Process..................................................................................108
5. The Multigenerational Transmission Process ...........................................................112
6. Sibling Position .........................................................................................................114
7. Emotional Cut-off .....................................................................................................116
8. Societal Emotional Processes....................................................................................118
Areas of assessment ..........................................................................................................................120
1) Spousal relationships.................................................................................................................120
2) De – Triangulation ....................................................................................................................121
3) Differentiation Of The Self and Emotional Cutoff...................................................................122
4) Understanding family emotional systems.................................................................................123
Normal Family Development............................................................................................................126
Family Disorders...............................................................................................................................126
Family Therapy with One Person .....................................................................................................126
Goals of Therapy...............................................................................................................................127
The practice of Bowen family therapy is governed by the following two goals: .........................127
Treatment entails...........................................................................................................................127
More specifically, the therapist .....................................................................................................127
Techniques ....................................................................................................................................128
Other concepts:..............................................................................................................................128
More about Triangles ........................................................................................................................129
1. Cross-generational coalitions ....................................................................................................129
2. The authors reviewed three family triangles:............................................................................129
3. The Emotionally Disturbed Child as the Family Scapegoat. ....................................................130
4. Marks, S. (1989). Towards a systems theory of marital quality. ..............................................131
seven different manifestations of the dual triangle construct........................................................131
Criticisms on the triangle theory ...................................................................................................132
Salvador Minuchin’s Structural Family Therapy ...........................................................................133
Contents.............................................................................................................................................133
Family Rules .....................................................................................................................................133
12

The family – homeostasis & change .............................................................................................135
The presenting problem.................................................................................................................136
The Process of Therapeutic Change..................................................................................................137
Therapeutic Goals and Techniques ...................................................................................................138
See also..............................................................................................................................................138
References .........................................................................................................................................138
Definitions.........................................................................................................................................139
Structure, subsystems and boundaries...........................................................................................139
Examples demonstrating boundaries and subsystems...................................................................139
Reaction to change: .......................................................................................................................140
As with boundaries, hierarchies can be either be too rigid or too weak .......................................140
Salvador Minuchin’s Style............................................................................................................140
Family member behaviour can be understood only in the family context. ...................................141
Counselors must differentiate between first-order and second-order changes. ............................141
Key concepts: ................................................................................................................................141
Three reasons that make clients move: .........................................................................................142
Conditions for behaviour change ..................................................................................................142
Four sources of family stress: .......................................................................................................142
Sets:...............................................................................................................................................142
Goals: ............................................................................................................................................142
How therapy addresses boundaries ...............................................................................................143
Interventions:.................................................................................................................................144
Assessment of therapy...................................................................................................................144
Four steps identified by Minuchin and his colleagues. .................................................................144
Therapy techniques : The seven steps of family therapy ..............................................................144
Step 1: joining and accommodating..............................................................................................144
Step 2: Enactment .........................................................................................................................145
Step 3: structural mapping ............................................................................................................145
Step 4: highlighting and modifying interactions...........................................................................145
Step 5: boundary making ..............................................................................................................145
Step 6: unbalancing .......................................................................................................................145
Step 7: challenging unproductive assumptions .............................................................................146
Conclusion.....................................................................................................................................146
Virginia Satir’s Humanistic Family Therapy...................................................................................147
Key concepts: ....................................................................................................................................147
Turn roles into relationships, rules into guidelines. ..................................................................147
Interventions:.....................................................................................................................................147
Criteria for termination: ....................................................................................................................148
Behavioural & Conjoint Family Therapy.......................................................................................149
Matching intent and impact of communication. ...............................................................................149
The four components in a family situation that are subject to change are........................................149
The three keys to Satir’s system are..................................................................................................149
Communication and Response Patterns ............................................................................................150
The counseling method of conjoint family therapy involves............................................................150
Games................................................................................................................................................150
The Counsellor’s Role.......................................................................................................................151
Key Concepts ....................................................................................................................................151
13

Milan Systemic Family Therapy or “Long Brief Therapy”..........................................................152
Key Concepts: ...................................................................................................................................152
Therapy: ............................................................................................................................................152
Interventions:.....................................................................................................................................152
Assessment....................................................................................................................................153
Family Development through a systemic lens ..............................................................................154
The process of change...................................................................................................................155
Roadblocks to family developmental change ...............................................................................157
Interventions that create a context for developmental change. .....................................................157
Conclusion.....................................................................................................................................158
Response-based Family Therapy .......................................................................................................159
Therapeutic Methods.........................................................................................................................159
References .........................................................................................................................................160
Related Reading ................................................................................................................................160
Contextual Family Therapy Approach .............................................................................................161
The core of Contextual Approach rests on two postulates................................................................161
Four-Dimensional Interventions .......................................................................................................162
Facts ..............................................................................................................................................162
Individual Psychology...................................................................................................................162
Transactions ..................................................................................................................................163
Critics ................................................................................................................................................163
Entitlement ........................................................................................................................................164
References and Bibliography ............................................................................................................165
Narrative Family Therapy .................................................................................................................166
Contents.............................................................................................................................................166
Overview ...........................................................................................................................................166
Narrative therapy topics ....................................................................................................................167
Concept .........................................................................................................................................167
Narrative approaches.....................................................................................................................167
Common elements.........................................................................................................................168
Method ..........................................................................................................................................168
Outsider Witnesses........................................................................................................................168
Definitions.........................................................................................................................................170
The identified patient ....................................................................................................................170
Homeostasis (Balance)..................................................................................................................170
The extended family field. ............................................................................................................170
Differentiation ...............................................................................................................................170
Triangular relationships ................................................................................................................170
Multisystemic Therapy..................................................................................................................170
Calibration:....................................................................................................................................170
Family Life Cycle: ........................................................................................................................171
Centrifugal/centripetal: .................................................................................................................171
Circular (mutual, reciprocal) causality:.........................................................................................171
Open/Closed systems: ...................................................................................................................171
14

Cybernetics:...................................................................................................................................171
Double bind...................................................................................................................................171
Equifinality / Equipotentiality:......................................................................................................171
First-order / Second-order change:................................................................................................171
Pseudo mutuality:..........................................................................................................................171
Punctuation:...................................................................................................................................172
Rules:.............................................................................................................................................172
Criticisms of Narrative Therapy........................................................................................................172
See also..............................................................................................................................................172
Theoretical foundations.................................................................................................................172
Related types of therapy................................................................................................................172
Other related concepts...................................................................................................................172
References .........................................................................................................................................172
We do not tell stories only: we are stories. .......................................................................................173
Basic Techniques in Family Therapy ................................................................................................174
OBSERVATION...............................................................................................................................174
IDENTIFICATION...........................................................................................................................174
I/ INFORMATION-GATHERING TECHNIQUES.........................................................................175
GETTING INFORMATION THROUGH USING OPEN-ENDED QUESTIONS. ....................175
THE GENOGRAM.......................................................................................................................175
THE FAMILY FLOORPLAN ......................................................................................................176
FAMILY PHOTOS.......................................................................................................................176
II/ JOINING ......................................................................................................................................177
1) TRACKING:.............................................................................................................................177
2) MIMESIS:.................................................................................................................................177
3) CONFIRMATION OF A FAMILY MEMBER: ......................................................................177
4) ACCOMMODATION:.............................................................................................................177
III/ DIAGNOSING...........................................................................................................................177
IV/ FAMILY SYSTEM STRATEGIES ..........................................................................................178
ASKING PROCESS QUESTIONS. .............................................................................................178
FAMILY SCULPTING ................................................................................................................178
FAMILY CHOREOGRAPHY......................................................................................................178
V/ INTERVENTION TECHNIQUES ..............................................................................................179
RELATIONSHIP EXPERIMENTS..............................................................................................179
COACHING..................................................................................................................................179
I-POSITIONS................................................................................................................................179
DISPLACEMENT STORIES. ......................................................................................................179
TAKING SIDE & MEDIATING..................................................................................................180
THE EMPTY CHAIR ...................................................................................................................180
FAMILY COUNCIL MEETINGS ...............................................................................................180
STRATEGIC ALLIANCES..........................................................................................................180
PRESCRIBING INDECISION.....................................................................................................180
PUTTING THE CLIENT IN CONTROL OF THE SYMPTOM.................................................180
SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS ..................................................181
PROBLEM SOLVING .................................................................................................................181
15

FAMILY CONTRACTS...............................................................................................................181
REFRAMING ...............................................................................................................................181
PUNCTUATION ..........................................................................................................................182
UNBALANCING .........................................................................................................................183
RESTRUCTURING......................................................................................................................183
ENACTMENT ..............................................................................................................................183
BOUNDARY FORMATION .......................................................................................................183
WORKING WITH SPONTANEOUS INTERACTION ..............................................................183
INTENSITY..................................................................................................................................183
SHAPING COMPETENCE..........................................................................................................183
ADDING COGNITIVE CONSTRUCTIONS ..............................................................................183
VI/ COMMUNICATION SKILL BUILDING TECHNIQUES.......................................................184
REFLECTING ..............................................................................................................................184
REPEATING.................................................................................................................................184
FAIR FIGHTING..........................................................................................................................184
TAKING TURNS EXPRESSING FEELINGS ............................................................................184
NONJUDGMENTAL BRAINSTORMING.................................................................................184
EFFECTIVE COMMUNICATION..............................................................................................185
Problem - Centered Systems Family Therapy..................................................................................186
Stages and Steps of Therapy .............................................................................................................186
Assessment....................................................................................................................................186
Contracting....................................................................................................................................186
Treatment ......................................................................................................................................186
Closure ..........................................................................................................................................186
A Guideline for Family Assessment .................................................................................................186
1. Orientation.................................................................................................................................186
2. Data Gathering ..........................................................................................................................186
3. Problem List ..............................................................................................................................186
4. Problem Clarification ................................................................................................................186
Summary of Dimension Concepts ....................................................................................................187
Problem-solving ............................................................................................................................187
Seven stages to the process ...........................................................................................................187
Communication .............................................................................................................................187
Roles..............................................................................................................................................187
Other family functions: .................................................................................................................187
Affective Responsiveness .............................................................................................................187
Affective Involvement ..................................................................................................................187
Behavior Control...........................................................................................................................187
Structure of a Family Therapy Session.............................................................................................188
Instructions........................................................................................................................................188
1. Research and Background.........................................................................................................188
2. Family Session ..........................................................................................................................188
Structure of Family Therapy .............................................................................................................189
A. Assumptions.................................................................................................................................190
B. Salvador Minuchin .......................................................................................................................190
C. Theoretical formulations - three essential constructs ...................................................................190
16

D. Normal family development.........................................................................................................191
E. The development of behaviour disorders .....................................................................................191
F. Goals of therapy............................................................................................................................191
G. Techniques — join, map, transform structure..............................................................................191
1. Joining and accommodating, then taking a position of leadership ...........................................191
2. Enactment for understanding and change .................................................................................191
3. Working with interaction and mapping the underlying structure .............................................191
4. Diagnosing ................................................................................................................................191
5. Highlighting and modifying interpersonal interactions is essential..........................................191
6. Boundary making and boundary strengthening ........................................................................192
7. Unbalancing may be necessary .................................................................................................192
8. Challenging the family’s assumptions may be necessary .........................................................192
9. Therapists must create techniques to fit each unique family ....................................................192
17

Systemic Family Therapy Manual.....................................................................................................197
1. Introduction ...................................................................................................................................197
1.1 Origins of the Manual .............................................................................................................197
1.2 Aims and applicability of the manual .....................................................................................197
1.3 Notes on use of manual ...........................................................................................................197
1.4 Ethical & Culturally Sensitive Practice..................................................................................198
1.5 Clinical Examples ............................................................................................................198
2. Guiding Principles.........................................................................................................................199
2.1 Systems Focus.........................................................................................................................199
2.2 Circularity ...............................................................................................................................199
2.3 Connections and Patterns ........................................................................................................199
2.4 Narratives and Language.........................................................................................................199
2.5 Constructivism ........................................................................................................................199
2.6 Social Constructionism ...........................................................................................................199
2.7 Cultural Context ......................................................................................................................199
2.8 Power.......................................................................................................................................200
2.9 Co-constructed therapy ...........................................................................................................200
2.10 Self-Reflexivity .....................................................................................................................200
2.11 Strengths and Solutions.........................................................................................................200
3. Outline of Therapeutic Change .....................................................................................................201
3.1 Models of Therapeutic Change ...............................................................................................201
3.2 Overview of Specific Goals ....................................................................................................202
4. Outline of Therapist Interventions ................................................................................................203
4.1 Linear Questioning..................................................................................................................203
4.2 Circular Questions...................................................................................................................203
4.3 Statements ...............................................................................................................................204
4.4 Reflecting Teams ....................................................................................................................204
4.5 Child Centred Interventions ....................................................................................................206
5. Therapeutic Setting .......................................................................................................................207
5.1 Convening Sessions ................................................................................................................207
5.2 Team........................................................................................................................................207
5.3 Video.......................................................................................................................................207
5.4 Pre-therapy preparation...........................................................................................................207
5.5 Pre & Post Session Preparation...............................................................................................208
5.6 Correspondence.......................................................................................................................209
5.7 Case notes................................................................................................................................209
5.8 Session notes ...........................................................................................................................209
6. Initial sessions ...............................................................................................................................210
Goals during initial session ...........................................................................................................210
6.1. Outline Therapy Boundaries & Structure ..............................................................................210
6.2 Engage and Involve all family members.................................................................................211
6.3 Gather and Clarify Information...............................................................................................211
6.4 Establish Goals and Objectives of Therapy ............................................................................211
Initial Session Checklist for Therapists.........................................................................................212
7. Middle Sessions ............................................................................................................................213
Goals during middle sessions........................................................................................................213
18

7.1 Develop engagement...............................................................................................................213
7.2 Gather Information & Focus Discussion.................................................................................213
7.3 Identify & Explore Beliefs ......................................................................................................213
7.4 Work towards change at the level of beliefs and behaviours..................................................215
7.5 Return to Objectives and Goals of Therapy............................................................................220
Middle Sessions Checklist for Therapists .....................................................................................220
8. End Sessions.................................................................................................................................222
Goals during ending sessions ........................................................................................................222
8.1 Gather Information & Focus Discussion.................................................................................222
8.2 Continue to work towards change at the level of behaviours and beliefs..............................222
8.3 Develop family understanding about behaviours and beliefs ...........................................223
8.4 Collaborative ending decision..........................................................................................223
8.5 Review the process of therapy ................................................................................................224
End Sessions Checklist for Therapists ..........................................................................................224
9. Indirect Work ................................................................................................................................225
9.1 Child Protection ......................................................................................................................225
9.2 Clarifying therapy with referrer present..................................................................................225
9.3 Identifying the network and clarifying relationships ..............................................................226
9.4 Assessing risk..........................................................................................................................226
10. Proscribed Practices ....................................................................................................................227
10.1 Advice ...............................................................................................................................227
10.2 Interpretation .........................................................................................................................227
10.3 Un-transparent/Closed Practice.............................................................................................227
10.4 Therapist monologues ...........................................................................................................227
10.5 Consistently siding with one person .....................................................................................227
10.6 Working in the transference ..................................................................................................227
10.7 Inattention to use of language ...............................................................................................227
10.8 Reflections.............................................................................................................................227
10.9 Polarised position ..................................................................................................................227
10.11 Sticking in one time frame ............................................................................................228
10.12 Agreeing / not challenging ideas...................................................................................228
10.13 Ignoring information that contradicts hypothesis ...............................................................228
10.14 Dismissing ideas..................................................................................................................228
10.15 Inappropriate affect .............................................................................................................228
10.16 Ignoring family affect .........................................................................................................228
10.17 Ignoring difference..............................................................................................................228
APPENDIXES......................................................................................................................................229
Appendix 1: Sample Appointment Letter ...........................................................................................229
Appendix II: Sample Video Consent Form.........................................................................................230
Appendix III: Sample Referrer letter ..................................................................................................231
Appendix IV: Post-assessment letter ................................................................................................232
Appendix V: Closing letter to referrer ..............................................................................................233
Appendix VI : Session Notes Record Form......................................................................................234
Appendix VII – Diagonistic Interview Outline.................................................................................236
19

BASIC FAMILY THERAPY TECHNIQUES .................................................................................239
ACCOMMODATION ..............................................................................................................239
ADVICE & INFORMATION...................................................................................................239
AFFECTIVE CONFRONTATION ..........................................................................................239
ASKING PERMISSION...........................................................................................................240
BEGINNER’S MIND ...............................................................................................................240
BOUNDARY FORMATION ...................................................................................................240
ADDING COGNITIVE CONSTRUCTIONS ..........................................................................241
1.Advice & Information ............................................................................................................241
2. Pragmatic fictions..................................................................................................................241
3. Paradox..................................................................................................................................241
COMMUNICATION TECHNIQUES......................................................................................241
1. MATCHING THE CLIENT’S LANGUAGE ......................................................................241
2. MATCHING SENSORY MODALITIES.............................................................................241
3. CHANNELING THE CLIENT’S LANGUAGE..................................................................241
4. USE OF VERB FORMS.......................................................................................................241
5. GIVE CLOSE EXAMINATION TO THEIR LANGUAGE AND YOURS........................241
COMMUNICATION SKILL-BUILDING TECHNIQUES.....................................................242
1. REFLECTING ......................................................................................................................242
2. REPEATING.........................................................................................................................242
3. FAIR FIGHTING TECHNIQUES........................................................................................242
CONCLUSION .........................................................................................................................242
CONFIRMATION OF A FAMILY MEMBER: ......................................................................242
DEFRAMING...........................................................................................................................242
DETRIANGULATION.............................................................................................................244
DIAGNOSING..........................................................................................................................244
DIFFERENTIATION OF SELF...............................................................................................244
DISEQUILIBRIUM TECHNIQUES........................................................................................244
1. REFRAMING: ......................................................................................................................244
3. BOUNDARY MAKING.......................................................................................................246
4. PUNCTUATION: .................................................................................................................247
4. UNBALANCING: ................................................................................................................247
LESSONS IN EFFECTIVE COMMUNICATION ..................................................................248
EMOTIONAL CUT-OFF .........................................................................................................249
THE EMPTY CHAIR ...............................................................................................................250
ENACTMENT ..........................................................................................................................250
FAMILY CHOREOGRAPHY..................................................................................................250
FAMILY CONTRACT.............................................................................................................250
FAMILY COUNCIL MEETINGS ...........................................................................................250
FAMILY FLOOR PLAN..........................................................................................................251
FAMILY LIFE CYCLE............................................................................................................251
FAMILY PHOTOS...................................................................................................................251
FAMILY SCULPTING ............................................................................................................251
FAMILY SYSTEM STRATEGIES..........................................................................................252
THE GENOGRAM...................................................................................................................252
GOAL SETTING ......................................................................................................................252
ICEBREAKER COMPLIMENT OR POSITIVE STATEMENT ............................................252
IDENTIFICATION...................................................................................................................253
INFORMATION-GATHERING TECHNIQUES ....................................................................253
1. The Genogram.......................................................................................................................253
20

2. Family Photos........................................................................................................................253
3. Family Floorplan...................................................................................................................253
INTENSITY..............................................................................................................................253
INTERVENTION TECHNIQUES ...........................................................................................253
INVOLUNTARY CLIENT SHEMA .......................................................................................253
JOINING...................................................................................................................................255
1. Tracking: ...........................................................................................................................255
2. Mimesis:............................................................................................................................255
3. Confirmation of a family member: ...................................................................................255
4. Accommodation: ...............................................................................................................255
5. Maintenance ......................................................................................................................256
NORMALIZATION .................................................................................................................256
OBSERVATION.......................................................................................................................258
POSITIVE CONNOTATION...................................................................................................258
PARADOXICAL INJUNCTIONS ...........................................................................................259
PRAGMATIC FICTIONS ........................................................................................................259
PRESCRIBING INDECISION.................................................................................................259
PROBLEM TRACKING ..........................................................................................................260
PROBLEM SOLVING TECHNIQUES ...................................................................................260
PROBLEM DISSOLUTION ....................................................................................................260
PUNCTUATION ......................................................................................................................260
PUTTING CLIENT IN CONTROL OF THE SYMPTOM......................................................260
QUESTIONS.............................................................................................................................261
1. THE MIRACLE QUESTION:.............................................................................................261
2. FAST-FORWARDING QUESTIONS .................................................................................261
3. THE EXCEPTION QUESTION:.........................................................................................261
4. STRATEGIC BASIC QUESTIONS:....................................................................................261
5. PROVOCATIVE QUESTIONS: ..........................................................................................261
6. SCALING QUESTIONS AND PERCENTAGE QUESTIONS ..........................................261
7. EXCEPTION SEEKING QUESTIONS ...............................................................................262
8. COPING QUESTIONS.........................................................................................................262
9. OPEN QUESTIONS .............................................................................................................263
10. PROCESS QUESTIONS. ..................................................................................................264
11. LINEAR QUESTIONS......................................................................................................264
12. CIRCULAR QUESTIONS .................................................................................................264
15. PROBLEM TRACKING QUESTIONS .............................................................................268
16. CONVERSATIONAL QUESTIONS ................................................................................270
17. FRAMING QUESTIONS ...................................................................................................272
18. DEFRAMING QUESTIONS..............................................................................................272
REFRAMING ...........................................................................................................................272
REFRAMING PROBLEM DEFINITIONS .............................................................................272
RESTRUCTURING..................................................................................................................273
SHAPING COMPETENCE......................................................................................................273
USE OF SILENCE....................................................................................................................273
SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS ..............................................274
WORKING WITH SPONTANEOUS INTERACTION ..........................................................274
STRATEGIC ALLIANCES......................................................................................................274
TRACKING ..............................................................................................................................274
UNBALANCING .....................................................................................................................275
INTRODUCING UNCERTAINTY..........................................................................................275
UTILIZATION STRATEGY....................................................................................................275
21

Summary of Family Therapy Theories & Techniques ....................................................................282
Family Therapy Survey ......................................................................................................................282
I. The Foundations of Family Therapy - Outline by David Peers.....................................................282
A. The myth of the hero ................................................................................................................282
B. Psychotherapeutic sanctuary ....................................................................................................282
C. Family vs. Individual therapy...................................................................................................282
D. Psychology and social context .................................................................................................282
E. The power of family therapy ....................................................................................................283
F. Contemporary cultural influences.............................................................................................283
G. Thinking in lines vs. Thinking in circles..................................................................................283
II. The Evolution Of Family Therapy - Outline by Lori Rice...........................................................284
A. The undeclared war ..................................................................................................................284
B. Small group dynamics ..............................................................................................................284
C. Child guidance movement........................................................................................................284
D. The influence of social work....................................................................................................284
E. Research on family dynamics and the etiology of schizophrenia.............................................284
III. Early Models And Basic Techniques - Outline by Sarah Sifers: ................................................285
A. Family therapy has a history of being condescending .............................................................285
B. Sketches of leading figures.......................................................................................................285
C. Theoretical formulations - group..............................................................................................285
D. Theoretical formulations - communications ............................................................................285
E. Normal family development .....................................................................................................286
F. Development of behavior disorders ..........................................................................................286
G. Goals of therapy .......................................................................................................................286
H. Conditions for behavior change ...............................................................................................286
I. Techniques of group family therapy..........................................................................................286
J. Techniques of communications family therapy.........................................................................286
K. Lessons from early models.......................................................................................................287
L. System’s anxiety.......................................................................................................................287
M. Stages of family therapy ..........................................................................................................287
N. Family assessment....................................................................................................................287
O. Working with managed care - it’s necessary, so cooperate .....................................................287
IV. The Fundamental Concepts Of Family Therapy - Outline by Anabella Pavon.........................288
A. Conceptual influences on the evolution of family therapy ......................................................288
B. Enduring concepts and methods...............................................................................................289
V. Bowen Family Systems Therapy - Outline by Jared Warren......................................................290
A. Sketches of leading figures ......................................................................................................290
B. Theoretical formulations ..........................................................................................................290
C. Normal family development.....................................................................................................290
D. Development of behaviour disorders .......................................................................................291
E. Goals of therapy........................................................................................................................291
F. Conditions for behavior change ................................................................................................291
G. Techniques ...............................................................................................................................291
H. Evaluating therapy theory and results ......................................................................................291
I. Summary - Seven prominent techniques ...................................................................................291
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VI. Experiential Family Therapy Outline by Sarah Sifers................................................................292
A. Leading figures and background ..............................................................................................292
B. Theoretical formulations ..........................................................................................................292
C. Normal family development.....................................................................................................292
D. Development of behavior disorders .........................................................................................292
E. Goals of therapy........................................................................................................................293
F. Conditions for behavior change ................................................................................................293
G. techniques.................................................................................................................................293
H. Evaluation.................................................................................................................................293
VII. Psychoanalytic Family Therapy Outline by Anabella Pavon....................................................294
A. Introduction ..............................................................................................................................294
B. Sketches of leading figures.......................................................................................................294
C. Theoretical formulations ..........................................................................................................294
D. Normal family development.....................................................................................................294
E. Development of behavior disorders..........................................................................................295
F. Goals of therapy........................................................................................................................295
G. Conditions for behavior change ...............................................................................................295
H. Techniques ...............................................................................................................................295
VIII. Structure Family Therapy — Outline by Patty Salehpur .........................................................296
A. Assumptions.............................................................................................................................296
B. Salvador Minuchin ...................................................................................................................296
C. Theoretical formulations - three essential constructs ...............................................................296
D. Normal family development.....................................................................................................296
E. The development of behavior disorders ...................................................................................296
F. Goals of therapy........................................................................................................................297
G. Techniques — join, map, transform structure..........................................................................297
23

Family Therapy – Background Information
From Wikipedia, the Free Encyclopedia
Family therapy, also referred to as couple and family therapy and family systems therapy, is a branch of
psychotherapy that works with families and couples in intimate relationships to nurture change and
development. It tends to view change in terms of the systems of interaction between family members. It
emphasizes family relationships as an important factor in psychological health.
What the different schools of family therapy have in common is a belief that, regardless of the origin of the
problem, and regardless of whether the clients consider it an "individual" or "family" issue, involving families in
solutions is often beneficial. This involvement of families is commonly accomplished by their direct
participation in the therapy session. The skills of the family therapist thus include the ability to influence
conversations in a way that catalyzes the strengths, wisdom, and support of the wider system.
In the field's early years, many clinicians defined the family in a narrow, traditional manner usually including
parents and children. As the field has evolved, the concept of the family is more commonly defined in terms of
strongly supportive, long-term roles and relationships between people who may or may not be related by blood
or marriage.
Family therapy has been used effectively in the full range of human dilemmas; there is no category of
relationship or psychological problem that has not been addressed with this approach. The conceptual
frameworks developed by family therapists, especially those of family systems theorists, have been applied to a
wide range of human behaviour, including organizational dynamics and the study of greatness.
Contents
1 History and theoretical frameworks
2 Techniques
3 Publications
4 Licensing and degrees
o 4.1 Values and ethics in family therapy
5 Founders and key influences
6 Summary of Family Therapy Theories & Techniques
7 Academic resources
8 Professional Organizations
9 See also
10 References
11 External links
25

History of Marital Therapy
Guman &Fränkel point out that couples therapy (formerly marital therapy) has been largely neglected, even
though family therapists do 1.5-2 times as much couple work as multigenerational family work. They also note
this is not such a bad ratio, as 40% of people coming to therapy attribute their problems to relationship issues.
(Gurman, A. S. & Fraenkel, P. (2002). The history of couple therapy: A millennial review. Family Process, 41,
199-260.)
G&F define Four Phases in the History of Couples Therapy:
Phase I - 1930 to 1963 - Atheoretical
1929 to 1932 - Three marital clinics opened; they were service and education oriented, and saw mostly
individuals
The closest thing to theory was what was borrowed from psychoanalytic - interlocking neurosis
1931 the first marital therapy paper was published
Theory was marginalized due to a lack of brilliant theorists, and a lack of distinction from individual
analysis
Phase II - 1931 to 1966 - Psychoanalytic Experimentation
Therapists are seen as telling truth from distortion, rather than creating a truth
Mostly individual sessions, but some conjoint; still treated like seeing two individual clients in the same
room though
Some started to downplay the role of the therapist
Family was outshining couples work, and the couple techniques weren't innovative or particularly
effective
Phase III - 1963 to 1985 - Family Therapy Incorporates
Family therapy overpowers couples, even though a number of big name people really mostly saw
couples
o Jackson
Coined concepts like quid pro quo, homeostasis, and double bind for conjoint therapy
o Satir
Coined naming roles members played, fostered self-esteem and actualization, and saw the
therapist as a nurturing teacher
o Bowen
Multigenerational theory approach, with differentiation, triangulation, and projection processes,
with the therapist as an anxiety-lowering coach - societal projection process was the forerunner
of our modern awareness of cultural differences.
o Haley
Power and control (or love and connection) were key. Avoided insight, emotional catharsis,
conscious power plays. Saw system as more, and more important, than the sum of the parts
Phase IV - 1986 to now - Refining and Integrating
1986 was the publication of G&K book
New Theories were tried and refined, like Behavioural Marital Therapy, Emotionally Focused Marital
Therapy, and Insight-Oriented Marital Therapy. All four have received good empirical support. Couples
therapy was used to treat depression, anxiety, and alcoholism.
Efforts were focused on preventing couples problems with programs like PREP
Feminism, Multiculturalism, and Post-Modernism impacted the field
Eclectic integration, brief therapy, and sex therapy ideas were incorporated into our work.
http://www.psychpage.com/family/library/history_of_couples_therapy.html
26

History and theoretical frameworks
Formal interventions with families to help individuals and families experiencing various kinds of problems have
been a part of many cultures, probably throughout history. These interventions have sometimes involved formal
procedures or rituals, and often included the extended family as well as non-kin members of the community (see
for example Ho'oponopono). Following the emergence of specialization in various societies, these interventions
were often conducted by particular members of a community – for example, a chief, priest, physician, and so on
- usually as an ancillary function.
Family therapy as a distinct professional practice within Western cultures can be argued to have had its origins
in the social work movements of the 19th century in England and the United States. As a branch of
psychotherapy, its roots can be traced somewhat later to the early 20th century with the emergence of the child
guidance movement and marriage counselling. The formal development of family therapy dates to the 1940s and
early 1950s with the founding in 1942 of the American Association of Marriage Counsellors (the precursor of
the AAMFT), and through the work of various independent clinicians and groups - in England (John Bowlby at
the Tavistock Clinic), the US (John Bell, Nathan Ackerman, Christian Midelfort, Theodore Lidz, Lyman
Wynne, Murray Bowen, Carl Whitaker, Virginia Satir), and Hungary (D.L.P. Liebermann) - who began seeing
family members together for observation or therapy sessions. There was initially a strong influence from
psychoanalysis (most of the early founders of the field had psychoanalytic backgrounds) and social psychiatry,
and later from learning theory and behaviour therapy - and significantly, these clinicians began to articulate
various theories about the nature and functioning of the family as an entity that was more than a mere
aggregation of individuals.
The movement received an important boost in the mid-1950s through the work of anthropologist Gregory
Bateson and colleagues – Jay Haley, Donald D. Jackson, John Weakland, William Fry, and later, Virginia Satir,
Paul Watzlawick and others – at Palo Alto in the US, who introduced ideas from cybernetics and general
systems theory into social psychology and psychotherapy, focusing in particular on the role of communication
(see Bateson Project). This approach eschewed the traditional focus on individual psychology and historical
factors – that involve so-called linear causation and content – and emphasized instead feedback and homeostatic
mechanisms and “rules” in here-and-now interactions – so-called circular causation and process – that were
thought to maintain or exacerbate problems, whatever the original cause(s). (See also systems psychology and
systemic therapy.) This group was also influenced significantly by the work of US psychiatrist, hypnotherapist,
and brief therapist, Milton H. Erickson - especially his innovative use of strategies for change, such as
paradoxical directives (see also Reverse psychology). The members of the Bateson Project (like the founders of
a number of other schools of family therapy, including Carl Whitaker, Murray Bowen, and Ivan Böszörményi-
Nagy) had a particular interest in the possible psychosocial causes and treatment of schizophrenia, especially in
terms of the putative "meaning" and "function" of signs and symptoms within the family system. The research
of psychiatrists and psychoanalysts Lyman Wynne and Theodore Lidz on communication deviance and roles
(e.g., pseudo-mutuality, pseudo-hostility, schism and skew) in families of schizophrenics also became
influential with systems-communications-oriented theorists and therapists.A related theme, applying to
dysfunction and psychopathology more generally, was that of the "identified patient" or "presenting problem" as
a manifestation of or surrogate for the family's, or even society's, problems. (See also double bind; family
nexus.)
By the mid-1960s a number of distinct schools of family therapy had emerged. From those groups that were
most strongly influenced by cybernetics and systems theory, there came MRI Brief Therapy, and slightly later,
strategic therapy, Salvador Minuchin's Structural Family Therapy and the Milan systems model. Partly in
reaction to some aspects of these systemic models, came the experiential approaches of Virginia Satir and Carl
Whitaker, which downplayed theoretical constructs, and emphasized subjective experience and unexpressed
feelings (including the subconscious), authentic communication, spontaneity, creativity, total therapist
engagement, and often included the extended family. Concurrently and somewhat independently, there emerged
the various intergenerational therapies of Murray Bowen, Ivan Böszörményi-Nagy, James Framo, and Norman
Paul, which present different theories about the intergenerational transmission of health and dysfunction, but
which all deal usually with at least three generations of a family (in person or conceptually), either directly in
therapy sessions, or via "homework", "journeys home", etc. Psychodynamic family therapy - which, more than
any other school of family therapy, deals directly with individual psychology and the unconscious in the context
of current relationships - continued to develop through a number of groups that were influenced by the ideas and
methods of Nathan Ackerman, and also by the British School of Object Relations and John Bowlby’s work on
attachment. Multiple-family group therapy, a precursor of psycho educational family intervention, emerged, in
27

part, as a pragmatic alternative form of intervention - especially as an adjunct to the treatment of serious mental
disorders with a significant biological basis, such as schizophrenia - and represented something of a conceptual
challenge to some of the "systemic" (and thus potentially "family-blaming") paradigms of pathogenesis that
were implicit in many of the dominant models of family therapy. The late-1960s and early-1970s saw the
development of network therapy (which bears some resemblance to traditional practices such as Ho'oponopono)
by Ross Speck and Carolyn Attneave, and the emergence of behavioural marital therapy (renamed behavioural
couples therapy in the 1990s; see also relationship counselling) and behavioural family therapy as models in
their own right.
By the late-1970s the weight of clinical experience - especially in relation to the treatment of serious mental
disorders - had led to some revision of a number of the original models and a moderation of some of the earlier
stridency and theoretical purism. There were the beginnings of a general softening of the strict demarcations
between schools, with moves toward rapprochement, integration, and eclecticism – although there was,
nevertheless, some hardening of positions within some schools. These trends were reflected in and influenced
by lively debates within the field and critiques from various sources, including feminism and post-modernism,
that reflected in part the cultural and political tenor of the times, and which foreshadowed the emergence (in the
1980s and 1990s) of the various "post-systems" constructivist and social constructionist approaches. While there
was still debate within the field about whether, or to what degree, the systemic-constructivist and medicalbiological
paradigms were necessarily antithetical to each other (see also Anti-psychiatry; Bio psychosocial
model), there was a growing willingness and tendency on the part of family therapists to work in multi-modal
clinical partnerships with other members of the helping and medical professions.
From the mid-1980s to the present the field has been marked by a diversity of approaches that partly reflect the
original schools, but which also draw on other theories and methods from individual psychotherapy and
elsewhere – these approaches and sources include: brief therapy, structural therapy, constructivist approaches
(e.g., Milan systems, post-Milan/collaborative/conversational, reflective), solution-focused therapy, narrative
therapy, a range of cognitive and behavioural approaches, psychodynamic and object relations approaches,
attachment and Emotionally Focused Therapy, intergenerational approaches, network therapy, and multi
systemic therapy (MST). Multicultural, intercultural, and integrative approaches are being developed. Many
practitioners claim to be "eclectic," using techniques from several areas, depending upon their own inclinations
and/or the needs of the client(s), and there is a growing movement toward a single “generic” family therapy that
seeks to incorporate the best of the accumulated knowledge in the field and which can be adapted to many
different contexts; however, there are still a significant number of therapists who adhere more or less strictly to
a particular, or limited number of, approach(es).
Ideas and methods from family therapy have been influential in psychotherapy generally: a survey of over 2,500
US therapists in 2006 revealed that of the ten most influential therapists of the previous quarter-century, three
were prominent family therapists, and the marital and family systems model was the second most utilized model
after cognitive behavioural therapy.
As we move through the 21st century, the internet is fostering the growth of online programs that make courses
and programs in family therapy more widely accessible. Using mass media techniques to increase public
understanding of issues in family therapy has added a new frontier for amplification in the future.
28

Techniques
Family therapy uses a range of counselling and other techniques including:
communication theory
media and communications psychology
psychoeducation
psychotherapy
relationship education
systemic coaching
systems theory
reality therapy
The number of sessions depends on the situation, but the average is 5-20 sessions.
A family therapist usually meets several members of the family at the same time. This has the advantage of
making differences between the ways family members perceive mutual relations as well as interaction patterns
in the session apparent both for the therapist and the family.
These patterns frequently mirror habitual interaction patterns at home, even though the therapist is now
incorporated into the family system.
Therapy interventions usually focus on relationship patterns rather than on analyzing impulses of the
unconscious mind or early childhood trauma of individuals as a Freudian therapist would do - although some
schools of family therapy, for example psychodynamic and intergenerational, do consider such individual and
historical factors (thus embracing both linear and circular causation) and they may use instruments such as the
genogram to help to elucidate the patterns of relationship across generations.
The distinctive feature of family therapy is its perspective and analytical framework rather than the number of
people present at a therapy session. Specifically, family therapists are relational therapists: They are
generally more interested in what goes on between individuals rather than within one or more
individuals, although some family therapists—in particular those who identify as psychodynamic, object
relations, intergenerational, EFT, or experiential family therapists—tend to be as interested in individuals as in
the systems those individuals and their relationships constitute.
Depending on the conflicts at issue and the progress of therapy to date, a therapist may focus on analyzing
specific previous instances of conflict, as by reviewing a past incident and suggesting alternative ways family
members might have responded to one another during it, or instead proceed directly to addressing the sources of
conflict at a more abstract level, as by pointing out patterns of interaction that the family might have not noticed.
Family therapists tend to be more interested in the maintenance and/or solving of problems rather than
in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to allocate
blame to one or more individuals, with the effect that for many families a focus on causation is of little or no
clinical utility.
29

Publications
Family therapy journals include: Journal of Marital and Family Therapy, Family Process, Journal of Family
Therapy, Journal of Systemic Therapies, The Australian & New Zealand Journal of Family Therapy, The
Psychotherapy Networker, The Journal of Sex and Marital Therapy, The Australian Journal of Family Therapy,
The International Journal of Narrative Therapy and Community Work, Journal for the Study of Human
Interaction and Family Therapy,
Licensing and degrees
Family therapy practitioners come from a range of professional backgrounds, and some are specifically
qualified or licensed/registered in family therapy (licensing is not required in some jurisdictions and
requirements vary from place to place). In the United Kingdom, family therapists are usually psychologists,
nurses, psychotherapists, social workers, or counsellors who have done further training in family therapy, either
a diploma or an M.Sc.. However, in the United States there is a specific degree and license as a Marriage and
Family therapist.
Prior to 1999 in California, counsellors who specialized in this area were called Marriage, Family and Child
Counsellors. Today, they are known as Marriage and Family Therapists (MFT), and work variously in private
practice, in clinical settings such as hospitals, institutions, or counselling organizations.
A master's degree is required to work as an MFT in some American states. Most commonly, MFTs will first
earn a M.S. or M.A. degree in marriage and family therapy, psychology, family studies, or social work. After
graduation, prospective MFTs work as interns under the supervision of a licensed professional and are referred
to as an MFTi.
Marriage and family therapists in the United States and Canada often seek degrees from accredited Masters or
Doctoral programs recognized by the Commission on Accreditation for Marriage and Family Therapy
Education(COAMFTE), a division of the American Association of Marriage and Family Therapy.
Requirements vary, but in most states about 3000 hours of supervised work as an intern are needed to sit for a
licensing exam. MFTs must be licensed by the state to practice. Only after completing their education and
internship and passing the state licensing exam can a person call themselves a Marital and Family Therapist and
work unsupervised.
License restrictions can vary considerably from state to state. Contact information about licensing boards in the
United States are provided by the Association of Marital and Family Regulatory Boards.
There have been concerns raised within the profession about the fact that specialist training in couples therapy –
as distinct from family therapy in general - is not required to gain a license as an MFT or membership of the
main professional body, the AAMFT.
Values and ethics in family therapy
Since issues of interpersonal conflict, power, control, values, and ethics are often more pronounced in
relationship therapy than in individual therapy, there has been debate within the profession about the different
values that are implicit in the various theoretical models of therapy and the role of the therapist’s own values in
the therapeutic process, and how prospective clients should best go about finding a therapist whose values and
objectives are most consistent with their own. Specific issues that have emerged have included an increasing
questioning of the longstanding notion of therapeutic neutrality, a concern with questions of justice and selfdetermination,
connectedness and independence, "functioning" versus "authenticity", and questions about the
degree of the therapist’s "pro-marriage/family" versus "pro-individual" commitment.
30

Founders and key influences
Some key developers of family therapy are:
Alfred Adler (phenomenology)
Nathan Ackerman (psychoanalytic)
Tom Andersen (Reflecting practices and dialogues about dialogues)
Harlene Anderson (Postmodern Collaborative Therapy and Collaborative Language Systems)
Harry J Aponte (Person-of-the-Therapist)
Gregory Bateson (1904–1980) (cybernetics, systems theory)
Ivan Böszörményi-Nagy (Contextual therapy, intergenerational, relational ethics)
Murray Bowen (Systems theory, intergenerational)
Steve de Shazer (solution focused therapy)
James Dobson (Christian psychologist) Focus on the Family
Milton H. Erickson (hypnotherapy, strategic therapy, brief therapy)
Richard Fisch (brief therapy, strategic therapy)
James Framo (object relations theory, intergenerational)
Edwin Friedman (Family process in religious congregations)
Harry Goolishian (Postmodern Collaborative Therapy and Collaborative Language Systems)
John Gottman (marriage)
Robert-Jay Green (LGBT, cross-cultural issues)
Jay Haley (strategic therapy, communications)
Lynn Hoffman (strategic, post-systems, collaborative)
Don D. Jackson (systems theory)
Sue Johnson (Emotionally focused therapy, attachment theory)
Bradford Keeney (cybernetics, resource focused therapy)
Walter Kempler (Gestalt psychology)
Bernard Luskin (media psychology, Public understanding of issues through media)
Cloe Madanes (strategic therapy)
Salvador Minuchin (structural)
Braulio Montalvo (structural)
[citation needed]
Virginia Satir (communications, experiential, conjoint and co-therapy)
Mara Selvini Palazzoli (Milan systems)
Ross Speck (network therapy)
Robin Skynner (Group Analysis)
Paul Watzlawick (Brief therapy, systems theory)
John Weakland (Brief therapy, strategic therapy, systems theory)
Carl Whitaker (Family systems, experiential, co-therapy)
Michael White (narrative therapy)
Lyman Wynne (Schizophrenia, pseudomutuality)
Principal Leaders in the Field:
Salvador Minuchin
Jay Haley
Murray Bowen
Nathan Ackerman
Virginia Satir
Ivan Boszmormenyi-Nagy
John Elderkin Bell
Philip Guerin
Don Jackson
Carl Whitaker
Betty Carter
Michael White
31

Salvador Minuchin
Born and raised in Argentina, Salvador Minuchin began his career as a family therapist in the early 1960's
when he discovered two patterns common to troubled families: some are "enmeshed," chaotic and
tightly interconnected, while others are "disengaged," isolated and seemingly unrelated. When
Minuchin first burst onto the scene, his immediate impact was due to his dazzling clinical artistry. This
compelling man with the elegant Latin accent would provoke, seduce, bully, or bewilder families into
changing -- as the situation required -- setting a standard against which other therapists still judge their best
work. But even Minuchin's legendary dramatic flair didn't have the same galvanizing impact as his
structural theory of families.
In his classic text, Families and Family Therapy (Minuchin, 1974) Minuchin taught family therapists to see
what they were looking at. Through the lens of structural family theory, previously puzzling interactions
suddenly swam into focus. Where others saw only chaos and cruelty, Minuchin helped us understand that
families are structured in "subsystems" with "boundaries," their members shadowing to steps they
do not see.
In 1962 Minuchin formed a productive professional relationship with Jay Haley, who was then in Palo Alto.
In 1965 Minuchin became the director of the Philadelphia Child Guidance Clinic, which eventually became
the world's leading center for family therapy and training. At the Philadelphia Clinic, Haley and Minuchin
developed a training program for members of the local black community as paraprofessional family
therapists in an effort to more effectively related to the urban blacks and Latinos in the surrounding
community.
In 1969, Minuchin, Haley, Braulio Montalvo, and Bernice Rosman developed a highly successful family
therapy training program that emphasized hands-on experience, on-line supervision, and the use of
videotapes to learn and apply the techniques of structural family therapy. Minuchin stepped down as
director of the Phildelphia Clinic in 1975 to pursue his interest in treating families with psychosomatic
illnesses and to continue writing some of the most influential books in the field of family therapy. In 1981,
Minuchin established Family Studies, Inc., in New York, a center committed to teaching family therapists.
Minuchin retired in 1996 and currently lives with his wife Patricia in Boston.
Jay Haley
A brilliant strategist and devastating critic, Jay Haley was a dominating figure in developing the Palo Alto
Group's communications model and strategic family therapy, which became popular in the 1970's. He
studied under three of the most influential pioneers in the evolution of family therapy - Gregory Bateson,
Milton Erickson, and Salvador Minuchin, and combined ideas from each of these innovative thinkers to
form his own unique brand of family therapy.
In 1953 Haley was studying for a master's degree in communication at Stanford University when Gregory
Bateson invited him to work on the schizophrenia project. Haley met with patients and their families to
observe the communicative style of schizophrenics in a natural environment. This work had an enormous
impact in shaping the development of family therapy.
Haley developed his therapeutic skills under the supervision of master hypnotist Milton Erickson from 1954
to 1960. Haley developed a brief therapy model which focused on the context and possible function of the
patient's symptoms and used directives to instruct patients to act in ways that were counterproductive to
their maladaptive behavior. Haley believed that it was far more important to get patients to actively do
something about their problems rather than help them to understand why they had these problems.
Haley was instrumental in bridging the gap between strategic and structural approaches to family therapy by
looking beyond simple dyadic relationships and exploring his interest in triangular, inter generational
relationships, or "perverse triangles." Haley believed that a patient's symptoms arose out of an
incongruence between manifest and covert levels of communication with others and served to give the
patient a sense of control in their interpersonal relationships. Accordingly, Haley thought that the
healing aspect of the patient-therapist relationship involved getting patients to take responsibility for their
actions and to take a stand in the therapeutic relationship, a process he called "therapeutic paradox."
Haley conducted research at the Mental Research Institute in Palo Alto until he joined Salvador Minuchin at
the Philadelphia Child Guidance Clinic in 1967. At the Philadelphia Clinic, Haley pursued his interests in
training and supervision in family therapy and was the director of family therapy research for ten years. He
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was also an active clinical member of the University of Pennsylvania's Department of Psychiatry. In 1976,
Haley moved to Washington D.C. and founded the Family Therapy Institute with Cloe Madanes, which has
become one of the major training institutes in the country. Haley retired in 1995 and currently lives in La
Jolla, California.
Murray Bowen
Among the pioneers of family therapy, Murray Bowen's emphasis on theory and insight as opposed to
action and technique distinguish his work from the more behaviorally oriented family therapists (Nichols &
Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Bowen's therapy is an
outgrowth of psychoanalytic theory and offers the most comprehensive view of human behavior and
problems of any approach to family therapy. The core goal underlying the Bowenian model is
differentiation of self, namely, the ability to remain oneself in the face of group influences, especially
the intense influence of family life. The Bowenian model also considers the thoughts and feelings of each
family member as well as the larger contextual network of family relationships that shapes the lie of the
family.
Bowen grew up in Waverly, Tennessee, the oldest child of a large cohesive family. After graduating from
medical school and serving five years in the military, Bowen pursued a career in psychiatry. He began
studying schizophrenia and his strong background in psychoanalytic training led him to expand his studies
from individual patients to the relationship patterns between mother and child. From 1946 to 1954, Bowen
studied the symbiotic relationships of mothers and their schizophrenic children at the Menninger Clinic in
Topeka, Kansas. Here he developed the concepts of anxious and functional attachment to describe
interactional patterns in the mother-child relationship.
In 1954, Bowen became the first director of the Family Division at the National Institute of Mental Health
(NIMH). He further broadened his attachment research to include fathers and developed the concept of
triangulation as the central building block o relationship systems (Nichols & Schwartz, 1998. Family
Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). In his first year at NIMH, Bowen provided
separate therapists for each individual member of a family, but soon discovered that this approach
fractionated families instead of bringing them together. As a result, Bowen decided to treat the entire family
as a unit, and became one of the founders of family therapy.
In 1959, Bowen began a thirty-one year career at Georgetown University's Department of Psychiatry where
he refined his model of family therapy and trained numerous students, including Phil Guerin, Michael Kerr,
Betty Carter, and Monica McGoldrick, and gained international recognition for his leadership in the field of
family therapy. He died in October 1990 following a lengthy illness.
Nathan Ackerman
Nathan Ackerman's astute ability to understand the overall organization of families enabled him to look
beyond the behavioral interactions of families and into the hearts and minds of each family member. He
used his strong will and provocative style of intervening to uncover the family's defenses and allow their
feelings, hopes, and desires to surface. Ackerman's training in the psychoanalytic model is evident in his
contributions and theoretical approach to family therapy. Ackerman proposed that underneath the
apparent unity of families there existed a wealth of intra psychic conflict that divided family
members into factions (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn &
Bacon 1998). Ackerman joined the Menninger Clinic in Topeka, Kansas, and became the chief psychiatrist
of the Child Guidance Clinic in 1937.
Initially, Ackerman followed the child guidance clinic model of having a psychiatrist treat the child and a
social worker see the mother (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn
& Bacon 1998). However, within his first year of work at the clinic, Ackerman became a strong advocate of
including the entire family when treating a disturbance in one of its members, and suggested that family
therapy be used as the primary form of treatment in child guidance clinics (Nichols & Schwartz, 1998.
Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon).
Ackerman was committed to sharing his ideas and theoretical approach with other professionals in the field.
In 1938 Ackerman published The Unity of the Family and Family Diagnosis: An Approach to the Preschool
Child, both of which inspired the family therapy movement. Together with Don Jackson, Ackerman
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founded the first family therapy journal, Family Process, which is still the leading journal of ideas in the
field today. In 1955 Ackerman organized the first discussion on family diagnosis at a meeting of the
American Ortho psychiatric Association to facilitate communication in the developing field of family
therapy.
In 1957 Ackerman established the Family Mental Health Clinic in New York City and began teaching at
Columbia University. He opened the Family Institute in 1960, which was later renamed the Ackerman
Institute after his death in 1971.
Virginia Satir
Virginia Satir is one of the key figures in the development of family therapy. She believed that a healthy
family life involved an open and reciprocal sharing of affection, feelings, and love. Satir made
enormous contributions to family therapy in her clinical practice and training. She began treating families in
1951 and established a training program for psychiatric residents at the Illinois State Psychiatric Institute in
1955.
Satir served as the director of training at the Mental Research Institute in Palo Alto from 1959-66 and at the
Esalen Institute in Big Sur beginning in 1966. In addition, Satir gave lectures and led workshops in
experiential family therapy across the country. She was well-known for describing family roles, such as "the
rescuer" or "the placator," that function to constrain relationships and interactions in families (Nichols &
Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon).
Satir's genuine warmth and caring was evident in her natural inclination to incorporate feelings and
compassion in the therapeutic relationship. She believed that caring and acceptance were key elements
in helping people face their fears and open up their hearts to others (Nichols & Schwartz, 1998. Family
Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Above all other therapists, Satir's was the most
powerful voice to wholeheartedly support the importance of love and nurturance as being the most
important healing aspects of therapy. Unfortunately, Satir's beliefs went against the more scientific approach
to family therapy accepted at that time, and she shifted her efforts away from the field to travel and lecture.
Satir died in 1988 after suffering from pancreatic cancer.
Ivan Boszmormenyi-Nagy
Ivan Boszmormenyi-Nagy's emphasis on loyalty, trust, and relational ethics -- both within the family and
between the family and society -- made major contributions to the field of family therapy since its inception
in the 1950's (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon 1998).
A student of Virginia Satir and an accomplished scholar and clinician, Nagy was trained as a psychoanalyst
and his work has encouraged many family therapists to incorporate psychoanalytic ideas with family
therapy.
Nagy is perhaps best known for developing the contextual approach to family therapy, which emphasizes
the ethical dimension of family development. Based on the psychodynamic model, contextual therapy
accentuates the need for ethical principles to be an integral part of the therapeutic process. Nagy believes
that trust, loyalty, and mutual support are the key elements that underlie family relationships and hold
families together, and that symptoms develop when a lack of caring and liability result in a breakdown of
trust in relationships (Nichols & Schwartz, Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon
1998). The therapists' role is to help the family work through avoided emotional conflicts and to develop a
sense of fairness among family members.
In 1957, Nagy established the Eastern Pennsylvania Psychiatric Institute (EPPI) and served as co director
and co therapist along with social worker Geraldine Spark. Nagy was also an active researcher of
schizophrenia and family therapy and coauthored Invisible loyalties: Reciprocity in intergenerational family
therapy (Boszormenyi-Nagy & Spark, 1973). Since the closing of EPPI, Nagy has continued to develop his
contextual approach to family therapy and remains associated with Hahnemann University in Pennsylvania.
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John Elderkin Bell
Perhaps one of the first family therapists was John Elderkin Bell, who began treating families in the early
1950's. Bell's ingenious approach to family therapy involved developing a step-by-step, easy-to-follow plan
of attack to treat family problems in stages. Bell's treatment approach was an outgrowth of group therapy
and was aptly named family group therapy. In 1951 Bell discovered that John Bowlby, a well-respected
clinician, was applying group psychotherapy techniques to treat individual families. Bell decided to follow
Bowlby's approach, and did not discover until many years later that Bowlby had only used this treatment
approach with one family.
Bell believed that the treatment of families should follow a series of three stages designed to
encourage communication among family members and to solve family problems.
In the first stage, the child-centered phase,
Bell encouraged children's involvement by facilitating the expression of their thoughts and feelings.
In the parent-centered stage,
parents responded to their children's concerns and often related difficulties they experienced with their
children's behavior.
The family-centered stage
was the final phase of treatment, and Bell continued to stimulate communication among family
members and to help solve family problems.
Unfortunately, Bell's pioneering efforts in the field of family therapy are less well-known as compared to
other family therapists. Bell did not publish his ideas until the 1960's, and he did not establish family
therapy clinics or training centers.
Philip Guerin
A student of Murray Bowen, Philip Guerin's own innovative ideas led to his developing a sophisticated
clinical approach to treating problems of children and adolescents, couples, and individual adults (Nichols
& Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Guerin's highly
articulated model outlines several therapeutic goals, which emphasize the multigenerational context of
families, working to calm the emotional level of family members, and defining specific patterns of
relationships within families. Guerin's family systems approach is designed to measure the severity of
conflict and to identify specific areas in need of improvement.
In 1970 Guerin became the Director of Training of the Family Studies Section at Albert Einstein College of
Medicine and Bronx State Hospital, a family therapy training center originally organized by Israel Zwerling
and Marilyn Mendelsohn. Guerin's pioneering efforts and exceptional leadership resulted in his establishing
an extramural training program in Westchester in 1972 and founding the Center for Family Learning in New
Rochelle, New York, one of the most exceptional family therapy programs for training and practice in the
nation (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon).
In addition to being a distinguished clinician, Guerin has authored some of the most influential and valuable
books and articles in the field of family therapy. Two of his best are: The Evaluation and treatment of
marital conflict: A four-stage approach (Guerin, 1987) and Working with relationship triangles: The onetwo-three
of psychotherapy (Guerin, Fogarty, Fay & Kautto, 1996).
Don Jackson
The vibrant and creative talent of Don Jackson contributed to his success as a writer, researcher, and
cofounder of the leading journal in the field of family therapy, Family Process. A 1943 graduate of Stanford
University School of Medicine, Jackson strongly rejected the psychoanalytic concepts that formed the basis
of his early training. Instead, he focused his interest on Bateson's analysis of communication and behavior,
which shaped his most important contributions to the developing field of family therapy.
By 1954, Jackson had developed a rudimentary family interactional therapy out of his pioneering work with
the Palo Alto group and research on schizophrenia (Nichols & Schwartz, 1998. Family Therapy: Concepts
and Methods. 4th ed. Allyn & Bacon). Jackson observed the mutual impact of schizophrenic patients and
their families in the home environment, and quickly recognized the importance of treating the family unit
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instead of removing patients for individual treatment. His early work centered on the effects of patients'
therapy on the entire family, and he developed the concept of family homeostasis to describe how
families resist change and seek to maintain redundant patterns of behavior. Jackson also suggested that
family members react to schizophrenic members' symptoms in ways that serve to stabilize the family's
status quo and often result in inflexible ways of thinking and maintain the symptomatic behavior (Nichols &
Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon).
In 1958, Jackson established the Mental Research Institute and worked with Virginia Satir, Jules Riskin, Jay
Haley, John Weakland, Paul Watzlawick and Bateson. By 1963, Jackson's model of the family involved
several types of rules that defined the communication patterns and interactions among family members.
Jackson believed that family dysfunction was a result of a family's lack of rules for change, and that
the therapist's role was to make the rules explicit and to reconstruct rigid which maintained family
problems. In 1968, tragically Jackson died by his own hand at the age of 48.
Carl Whitaker
Carl Whitaker's creative and spontaneous thinking formed the basis of a bold and inventive approach to
family therapy. He believed that active and forceful personal involvement and caring of the therapist was
the best way to bring about changes in families and promote flexibility among family members. He relied
on his own personality and wisdom, rather than any fixed techniques, to stir things up in families and to help
family members open up and be more fully themselves (Nichols & Schwartz, 1998. Family Therapy:
Concepts and Methods. 4th ed. Allyn & Bacon). Whitaker's confrontive approach earned him the reputation
as the most irreverent among family therapy's iconoclasts.
Whitaker viewed the family as an integrated whole, not as a collection of discrete individuals, and felt
that a lack of emotional closeness and sharing among family members resulted in the symptoms and
interpersonal problems that led families to seek treatment. He equated familial togetherness and
cohesion with personal growth, and emphasized the importance of including extended family members,
especially the expressive and playful spontaneity of children, in treatment. A big, comfortable, lanternjawed
man, Whitaker liked a crowd in the room when he did therapy. Whitaker also pioneered the use of co
therapists as a means of maintaining objectivity while using his highly provocative techniques to turn up the
emotional temperature of families (Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th
ed. Allyn & Bacon).
Beginning in 1946, Whitaker served as Chairman of the Department of Psychiatry at Emory University,
where he focused on treating schizophrenics and their families. He also helped to develop some of the first
major professional meetings of family therapists with colleagues such as John Warkentin, Thomas Malone,
John Rosen, Bateson, and Jackson. In 1955, Whitaker left Emory to enter into private practice, and became
a professor of Psychiatry at the University of Wisconsin in 1965 until his retirement in 1982. Whitaker died
in April 1995, leaving a heartfelt void in the field of family therapy.
Betty Carter
An ardent and articulate feminist, Betty Carter was instrumental in enriching and popularizing the concept
of the family life cycle and its value in assessing families. Carter entered the field of family therapy after
being trained as a social worker, and emphasized the importance of historical antecedents of family
problems and the multigenerational aspects of the life cycle that extended beyond the nuclear family.
Carter further expanded on the family life cycle concept by considering the stages of divorce and remarriage
(Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon).
Carter's interest in family therapy was stimulated by taking part in a family therapy field placement at the
Ackerman Institute as part of her M.S.W. requirements at Hunter College. She quickly became an avid
student of the Bowenian model, and served on the staff of the Family Studies Section at Albert Einstein
College of Medicine and Bronx State Hospital with Phil Guerin and Monica McGoldrick. Carter left the
Center for Family Learning to become the founding director of the Family Institute of Westchester in 1977.
Carter served as Co director of the Women's Project in Family Therapy with Peggy Papp, Olga Silverstein,
and Marianne Walters, and has been an outspoken leader about the gender and ethnic inequalities that serve
to keep women in inflexible family roles.
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Currently, Carter is an active clinician and specializes in marital therapy and therapy with remarried couples
(Nichols & Schwartz, 1998. Family Therapy: Concepts and Methods. 4th ed. Allyn & Bacon). Her work
with couples focuses on helping her clients to understand their situation and to address unresolved family
issues. Carter incorporates tasks, such as letter writing, which serve to intensify and speed up the
communication process and help couples move out of rigid patterns of behavior.
Michael White
Michael White, the guiding genius of narrative family therapy, began his professional life as a mechanical
draftsman. But he soon realized that he preferred people to machines and went into social work where he
gravitated to family therapy. Following an initial attraction to the cybernetic thinking of Gregory Bateson,
White became more interested in the ways people construct meaning in their lives than just with the ways
they behaved.
In developing the notion that people's lives are organized by their life narratives, White came to
believe that stories don't mirror life, they shape it. That's why people have the interesting habit of
becoming the stories they tell about their experience.
Narrative therapists break the grip of unhelpful stories by externalizing problems. By challenging
fixed and pessimistic versions of events, therapists make room for flexibility and which new and more
optimistic stories can be envisioned. Finally, clients are encouraged to create audiences of support to
witness and promote their progress in restoring their lives along preferred lines.
White's innovative thinking helped shape the basic tenets of narrative therapy, which considers the broader
historical, cultural and political framework of the family. In the narrative approach, therapists try to
understand how clients' personal beliefs and perceptions, or narratives, shape their self-concept and
personal relationships. Individual clients of families are then encouraged to reconstruct their
narratives to facilitate more adaptive views of themselves and more effective interpersonal
interactions.
White's leadership of the narrative movement in family therapy is based not only on his imaginative ideas
but also on his inspirational persistence in seeing the best in people even when they've lost faith in
themselves. White is well-known for his persistence in challenging clients' negative self-beliefs and for his
relentless optimism in helping people to develop healthier interpretations of their life experiences. White's
tenaciously positive attitude has undoubtedly contributed to his enormous success as a therapist.
Currently, White lives in Adelaide, South Australia. Together with his wife, Cheryl, White works at the
Dulwich Centre, a training and clinical facility that also publishes the Dulwich Newsletter, which White
uses to explore his ideas with the field.
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Models and Schools
Family therapists and counselors use a range of methods and over the years a number of models or schools
of family therapy have developed.
A well-known classification of these approaches is described by Gurman and Kniskern (1991):
1. Behavioural Family Therapy
2. Bowen theory
3. Brief Therapy: MRI
4. Contextual Therapy
5. Eriscksonian Family Therapy
6. Focal Family Therapy
7. Milan Systemic Therapy
8. Family Psychoeducational Therapy
9. Strategic Therapy
10. Structural Therapy
11. Symbolic-Experiential Therapy
Some contemporary family therapies:
Structural Family Therapy (Minuchin, 1974, Colapinto, 1991)
In this type of therapy, the structural therapist believes that change of behaviour is most important.
Therapy begins with the therapist “joining” with the family. He or she has the purpose to enhance the
feeling of worth of individual family members. The therapist must attune himself or herself to the families
value systems and existing hierarchies. After “joining”, the therapist challenges “how things are done“
and begins restructuring the family by offering alternative, more functional ways of behaving.
Conjoint Family Therapy (Satir, 1967)
Conjoint family therapy works with personal experiences and helps experiencing the value of the
individual within the family system. Therapists use all levels of communication to express the relational
qualities present in the family to achieve change in family system. This approach uses many feeling and
communication exercises and games, for example family sculpture.
Contextual Therapy (Boszormenyi-Nagy, 1991)
In the contextual approach the word “context“ indicates the dynamic connectedness of a person with her
or his significant relationships, the long-term relational involvement as well as the person’s
relatedness to his or her multigenerational roots. The therapist encourages family members to explore
their own multilaterality.
Strategic Therapy (Madanes, 1981)
In this approach, the therapist considers the therapy in terms of step-by-step change in the way from one
type of abnormal organisation to another type before a more normal organisation is finally achieved.
For a strategic therapist two questions are basic: How is the symptom “helping” the family to maintain a
balance or overcome a crisis? How can the symptom be replaced by a more effective solution of the
problem?
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Brief Therapy
This name refers not only to the duration of the therapy, but it represents comprehensively a way of
orientation in therapeutic practice. Problem formation and maintenance is seen as parts of vicious-circle
process, in which maladaptive “solutions“ behaviours maintain the problem. Alteration of these
behaviours /or beliefs/ should interrupt the cycle and initiate the resolution of the problem.
Milan Systemic Therapy (Boscolo et al, 1987)
Basic assumption of Milan Systemic Therapy is that mind is social. The symptomatic behaviour is
conceived as a part of the transactional patterns of the system. Significance of any particular behaviour or
event may be derived from its social context. The therapists consider that the way to eliminate the symptom
which is present in the family is to change the rules and beliefs. Change is achieved in clarifying the
ambiguity in relationships.
Narrative Therapy (Freedman, Combs, 1996)
The followers of the narrative approach consider that experience rooted in the life events is elaborated in the
form of a story, which gives to these events a meaning reflecting the systems of belief. In the therapy
process, the “life story” of a family is connected with the internal and external culture of the family.
Change is enabled by retelling the story, in the course of which meanings attributed to the events can
change or alternate. http://www.dmrtk.jgytf.u-szeged.hu/phare/eng/more.htm
Academic resources
Family Process
Journal of Child and Family Studies, ISSN: 1062-1024 (Print) 1573-2843 (Online), Springer
Journal of Marital and Family Therapy
Journal of Family Psychology
Family Relations
Contemporary Family Therapy
Australian & New Zealand Journal of Family Therapy
Family Matters, Australian Institute of Family Studies
Journal of Comparative Family Studies, ASIN: B00007M2W5, Univ of Calgary/Dept Sociology
Journal of Family Studies, ISSN: 1322-9400, eContent Management Pty Ltd
Journal of Family Therapy, AFT (Association for family Therapy & Systemic Practice in the UK)
Context Magazine, AFT, UK
Karnac Systemic Thinking and Practice Series
Professional Organizations
American Association for Marriage and Family Therapy
American Family Therapy Academy
European Family Therapy Association (EFTA)
International Association of Marriage and Family Counsellors
National Council on Family Relations
The Ackerman Institute for the Family
39

Useful Internet links
Wikipedia links
Alternative dispute resolution
CAMFT
Child abuse
Conflict resolution
Deinstitutionalisation
Domestic violence
Dysfunctional family
Family Life Education
Family Life Space
External links
Internal Family Systems Model
Interpersonal psychotherapy
Interpersonal relationship
Mediation
Multisystemic Therapy (MST)
Positive psychology
Relationships Australia
Strategic Family Therapy
Included in this list are the main professional associations in the US and internationally; they reflect to some
degree the different theoretical, ideological, and cross-cultural views of family therapy theory and practice.
American Association for Marriage and Family Therapy: main professional association in US
American Family Therapy Academy: main research-oriented professional association in US
Association for Family Therapy and Systemic Practice in the UK
Australian and New Zealand Journal of Family Therapy: the de facto professional association for
Australia and NZ
Bowen Theory from the Bowen Centre for the Study of the Family.
California Association of Marriage and Family Therapists
European Family Therapy Association
International Family Therapy Association
Historical overview of the field; Therapist profiles; Timeline from Allyn and Bacon/Longman
publishing.
Family Support Partnership - An Overview of Family Therapy and Mediation
Dulwich Centre: Gateway to Narrative Therapy & Community Work
"Mind For Therapy" group devoted to creative origins of Family Therapy
Glossary of Family Systems and intergenerational concepts
MFT at Notre Dame de Namur University, Belmont CA
Social Construction Therapies Network
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Brief Strategic Family Therapy
From Wikipedia, the free encyclopedia
The family is defined by an organizational structure that is characterized by degrees of cohesiveness, love,
loyalty, and purpose as well as high levels of shared values, interests, activities, and attention to the needs of
its members. Families may be considered a system, organized wholes or units made up of several
interdependent and interacting parts. Each member has a significant influence on all other members. For
positive change in an identified client, therefore, family members have to change the way they
interact. Family therapists work with the present relationships rather than the past. They are interested in
the balance families maintain between bipolar extremes that characterize dysfunctional families.
Strategic refers to the development of a specific strategy, planned in advance by the therapist, to resolve the
presenting problem as quickly and efficiently as possible.
DESCRIPTION
Brief Strategic Family Therapy (BSFT) is a short-term, problem-focused therapeutic intervention, targeting
children and adolescents 6 to 17 years old, that improves youth behaviour by eliminating or reducing drug
use and its associated behaviour problems and that changes the family members’ behaviours that are linked
to both risk and protective factors related to substance abuse. The therapeutic process uses techniques of:
PROGRAM BACKGROUND
BSFT was developed at the Spanish Family Guidance Center in the Center for Family Studies, University of
Miami. BSFT has been conducted at these centers since 1975. The Center for Family Studies is the Nation’s
oldest and most prominent center for development and testing of minority family therapy interventions for
prevention and treatment of adolescent substance abuse and related behaviour problems. It is also the
Nation’s leading trainer of research-proven, family therapy for Hispanic/Latino families.
INDICATED
This program was developed for an indicated audience. It targets children with conduct problems,
substance use, problematic family relations, and association with antisocial peers.
CONTENT FOCUS
ALCOHOL, ANTISOCIAL/AGGRESSIVE BEHAVIOUR, ILLEGAL DRUGS, TOBACCO
SOCIAL AND EMOTIONAL COM PETENCE.
This program addresses family risk and protective factors to problem behaviour, including
substance use among adolescents.
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INTERVENTIONS BY DOMAIN
PARENTS AS A PRIMARY TARGET POPULATION:
The program involves family systems therapy, involving all family members. It seeks to change the way
family members act toward each other so that they will promote each other’s mastery over
behaviours that are required for the family to achieve competence and to impede undesired
behaviours.
INDIVIDUAL:
Life and social skills training
FAMILY :
Home visits, Parent education/family therapy, Parent education/parenting skills training
Task-oriented family education sessions combining social skills training to improve family interaction
(e.g., communication skills)
PEER :
Peer-resistance education
KEY PROGRAM APPROACHES
PARENT-CHILD INTERACTION:
All of the key strategies are focused on improving the interactions between parents and child.
PARENT TRAINING:
A key change strategy is to empower parents by increasing their mastery of parenting skills.
SKILL DEVELOPMENT:
The program fosters conflict resolution skills, parenting skills, and communication skills.
TECHNIQUES USED
Joining—forming a therapeutic alliance with all family members
Diagnosis—identifying interactional patterns that allow or encourage problematic youth behaviour
Restructuring—the process of changing the family interactions that are directly related to problem
behaviours
THERAPY
The program involves creating a counsellor-family work team that develops a therapeutic alliance with each
family member and with the family as a whole; diagnosing family strengths and problematic interactions;
developing change strategies to capitalize on strengths and correct problematic family interactions; and
implementing change strategies and reinforcing family behaviours that sustain new levels of family
competence. Strategies include reframing, changing alliances, building conflict resolution skills, and
parental empowerment.
HOW IT WORKS
BSFT can be implemented in a variety of settings, including community social services agencies, mental
health clinics, health agencies, and family clinics. BSFT is delivered in 8 to 12 weekly 1- to 1.5-hour
sessions. The family and BSFT counsellor meet either in the program office or the family’s home. Sessions
may occur more frequently around crises because these are opportunities for change.
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There are four important BSFT steps:
Step 1: Organize a counsellor-family work team.
Development of a therapeutic alliance with each family member and with the family as a whole is
essential for BSFT. This requires counsellors to accept and demonstrate respect for each individual family
member and the family as a whole.
Step 2: Diagnose family strengths and problem relations.
Emphasis is on family relations that are supportive and problem relations that affect youths’ behaviours or
interfere with parental figures’ ability to correct those behaviours.
Step 3: Develop a change strategy
Develop a change strategy to capitalize on strengths and correct problematic family relations,
thereby increasing family competence. In BSFT, the counsellor is plan- and problem-focused,
direction-oriented (i.e., moving from problematic to competent interactions), and practical.
Step 4: Implement change strategies and reinforce family behaviours that sustain new levels of family
competence.
Important change strategies include reframing to change the meaning of interactions; changing alliances
and shifting interpersonal boundaries; building conflict resolution skills; and providing parenting guidance
and coaching.
BARRIERS AND PROBLEMS
Problem: The most common problem is engaging and retaining whole families in treatment.
Solution: Specialized engagement strategies have been developed to deal with the problem.
Problem: A common problem in implementing a whole-family intervention involves limited availability of
family members.
Solution: Sessions often must occur during evening hours and on weekends.
43

Brief Strategic Family Therapy for Adolescent
Drug Abuse
The National Institute on Drug Abuse (NIDA) is part of the National Institutes of Health (NIH) , a
component of the U.S. Department of Health and Human Services. Questions? See our Contact Information
Foreword
More than 20 years of research has shown that addiction is clearly treatable. Addiction treatment has been
effective in reducing drug use and HIV infection, diminishing the health and social costs that result from
addiction, and decreasing criminal behavior. The National Institute on Drug Abuse (NIDA), which supports
more than 85 percent of the world's research on drug abuse and addiction, has found that behavioral
approaches can be very effective in treating cocaine addiction.
To ensure that treatment providers apply the most current scientifically supported approaches to their
patients, NIDA has supported the development of the "Therapy Manuals for Drug Addiction" series. This
series reflects NIDA's commitment to rapidly applying basic findings in real life settings. The manuals are
derived from those used efficaciously in NIDA-supported drug abuse treatment studies. They are intended
for use by drug abuse treatment practitioners, mental health professionals, and all others concerned with the
treatment of drug addiction.
The manuals present clear, helpful information to aid drug treatment practitioners in providing the best
possible care that science has to offer. They describe scientifically supported therapies for addiction and
provide guidance on session content and how to implement specific techniques. Of course, there is no
substitute for training and supervision, and these manuals may not be applicable to all types of patients nor
compatible with all clinical programs or treatment approaches. These manuals should be viewed as a
supplement to, but not a replacement for, careful assessment of each patient, appropriate case formulation,
ongoing monitoring of clinical status, and clinical judgment.
The therapies presented in this series exemplify the best of what we currently know about treating drug
addiction. As our knowledge evolves, new and improved therapies are certain to emerge. We look forward
to continuously bringing you the latest scientific findings through manuals and other science-based
publications. We welcome your feedback about the usefulness of this manual series and any ideas you have
about how it might be improved.
Nora D. Volkow, M.D.
Director
National Institute on Drug Abuse
44

Chapter 1 - Brief Strategic Family Therapy: An Overview
Brief Strategic Family Therapy (BSFT) is a brief intervention used to treat adolescent drug use that
occurs with other problem behaviors. These co-occurring problem behaviors include conduct problems at
home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and
violent behavior, and risky sexual behavior (Jessor and Jessor 1977; Newcomb and Bentler 1989; Perrino et
al. 2000).
BSFT is based on three basic principles.
The first is that BSFT is a family systems approach. Family systems means that family members are
interdependent: What affects one family member affects other family members. According to family
systems theory, the drug-using adolescent is a family member who displays symptoms, including drug use
and related co-occurring problem behaviors. These symptoms are indicative, at least in part, of what else is
going on in the family system (Szapocznik and Kurtines 1989). Just as important, research shows that
families are the strongest and most enduring force in the development of children and adolescents
(Szapocznik and Coatsworth 1999). For this reason, family-based interventions have been studied as
treatments for drug-abusing adolescents and have been found to be efficacious in treating both the drug
abuse and related co-occurring problem behaviors (for reviews, see Liddle and Dakof 1995; Robbins et al.
1998; Ozechowski and Liddle 2000).
The second BSFT principle is that the patterns of interaction in the family influence the behavior of each
family member. Patterns of interaction are defined as the sequential behaviors among family members that
become habitual and repeat over time (Minuchin et al. 1967). An example of this is an adolescent who
attracts attention to herself when her two caregivers (e.g., her mother and grandmother) are fighting as a
way to disrupt the fight. In extreme cases, the adolescent may suffer a drug overdose or get arrested to
attract attention to herself when her mother and grandmother are having a very serious fight.
The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the
adolescent's behavior problems. For example, a mother and grandmother who are arguing about establishing
rules and consequences for a problem adolescent never reach an agreement because the adolescent disrupts
their arguments with self-destructive attempts to get attention.
The third principle of BSFT consequently is to plan interventions that carefully target and provide practical
ways to change those patterns of interaction (e.g., the way in which mother and grandmother attempt but fail
to establish rules and consequences) that are directly linked to the adolescent's drug use and other problem
behaviors.
45

Why Brief Strategic Family Therapy?
The scientific literature describes various treatment approaches for adolescents with drug addictions,
including behavioral therapy, multisystemic therapy, and several family therapy approaches. Each of these
approaches has strengths.
BSFT's strengths include the following:
BSFT is an intervention that targets self-sustaining changes in the family environment of the
adolescent. That means that the treatment environment is built into the adolescent's daily family
life.
BSFT can be implemented in approximately 8 to 24 sessions. The number of sessions needed
depends on the severity of the problem.
BSFT has been extensively evaluated for more than 25 years and has been found to be efficacious
in treating adolescent drug abuse, conduct problems, associations with antisocial peers, and
impaired family functioning.
BSFT is "manualized," and training programs are available to certify BSFT counselors.
BSFT is a flexible approach that can be adapted to a broad range of family situations in a variety of
service settings (e.g., mental health clinics, drug abuse treatment programs, and other social service
settings) and in a variety of treatment modalities (e.g., as a primary outpatient intervention, in
combination with residential or day treatment, and as an aftercare/continuing-care service to
residential treatment).
BSFT appeals to cultural groups that emphasize family and interpersonal relationships.
What Are the Goals of Brief Strategic Family Therapy?
In BSFT, whenever possible, preserving the family is desirable. While family preservation is important,
two goals must be set: to eliminate or reduce the adolescent's use of drugs and associated problem
behaviors, known as "symptom focus," and to change the family interactions that are associated with the
adolescent's drug abuse, known as "system focus." An example of the latter occurs when families direct
their negative feelings toward the drug-abusing youth. The parents' negativity toward the adolescent directly
affects his or her drug abuse, and the adolescent's drug abuse increases the parents' negativity. At the family
systems level, the counselor intervenes to change the way family members act toward each other (i.e.,
patterns of interaction). This will prompt family members to speak and act in ways that promote more
positive family interaction, which, in turn, will make it possible for the adolescent to reduce his or her drug
abuse and other problematic behaviors.
What Are the Most Common Problems Facing the Family of a Drug-Abusing Adolescent?
The makeup and dynamics of the family are discussed in terms of the adolescent's symptoms and the
family's problems.
46

The Family Profile of a Drug-Abusing Adolescent
Research shows that many adolescent behavior problems have common causes and that families, in
particular, play a large role in those problems in many cases (Szapocznik and Coatsworth 1999). Some of
the family problems that have been identified as linked to adolescent problem behaviors include:
Parental drug use or other antisocial behavior
Parental under- or over-involvement with the adolescent
Parental over- or under-control of the adolescent
Poor quality of parent-adolescent communication
Lack of clear rules and consequences for adolescent behavior
Inconsistent application of rules and consequences for adolescent behavior
Inadequate monitoring and management of the adolescent's activities with peers
Lack of adult supervision of the adolescent's activities with peers
Poor adolescent bonding to family
Poor family cohesiveness
Some adolescents may have families who had these problems before they began using drugs (Szapocznik
and Coatsworth 1999). Other families may have developed problems in response to the adolescent's
problem behaviors (Santisteban et al. in press).
Because family problems are an integral part of the profile of drugabusing adolescents and have been linked
to the initiation and maintenance of adolescent drug use, it is necessary to improve conditions in the youth's
most lasting and influential environment: the family. BSFT targets all of these family problems.
The Behavioral Profile of a Drug-Abusing Adolescent
Adolescents who need drug abuse treatment usually exhibit a variety of externalizing behavior problems.
These may include:
School truancy
Delinquency
Associating with antisocial peers
Conduct problems at home and/or school
Violent or aggressive behavior
Oppositional behavior
Risky sexual behavior
Negativity in the Family
Families of drug-abusing adolescents exhibit high degrees of negativity (Robbins et al. 1998). Very often,
this negativity takes the form of family members blaming each other for both the adolescent's and the
family's problems. Examples might include a parent who refers to her drug-abusing son as "no good" or "a
lost cause." Parents or parent figures may blame each other for what they perceive as a failure in raising the
child. For example, one parent may accuse the other of having been a "bad example," or for not "being
there" when the youngster needed him or her. The adolescent, in turn, may speak about the parent accused
of setting a bad example with disrespect and resentment. The communication among family members is
contaminated with anger, bitterness, and animosity. To the BSFT counselor, these signs of emotional or
affective distress indicate that the work of changing dysfunctional behaviors must start with changing the
negative tone of the family members' emotions and the negative content of their interactions. Research
shows that when family negativity is reduced early in treatment, families are more likely to remain in
therapy (Robbins et al. 1998).
47

What Is Not the Focus of Brief Strategic Family Therapy?
BSFT has not been tested with adult addicts. For this reason, BSFT is not considered a treatment for adult
addiction. Instead, when a parent is found to be using drugs, a counselor needs to decide the severity of the
parent's drug problem. A parent who is moderately involved with drugs can be helped as part of his or her
adolescent's BSFT treatment. However, if a parent is drug dependent, the BSFT counselor should work to
engage the parent in drug abuse treatment. If the parent is unwilling to get drug abuse treatment, the BSFT
counselor should work to protect and disengage the adolescent from the drug dependent parent. This is done
by creating an interpersonal wall or boundary that separates the adolescent and non-drug-using family
members from the drug dependent parent(s). This process is discussed in Chapter 4 in the section on
"Working With Boundaries and Alliances".
This Manual
This manual introduces counselors to concepts that are needed to understand the family as a vital context
within which adolescent drug abuse occurs. It also describes strategies for creating a therapeutic relationship
with families, assessing and diagnosing maladaptive patterns of family interaction, and changing patterns of
family interaction from maladaptive to adaptive. This manual assumes that therapists who adopt these BSFT
techniques will be able to engage and retain families in drug abuse treatment and ultimately cause them to
behave more effectively. Chapter 2 will discuss the basic theoretical concepts of BSFT. Chapter 3 will
present the BSFT diagnostic approach, and Chapter 4 will explain how change is achieved. Chapter 5 is a
detailed discussion of how to engage resistant families of drug-abusing adolescents in treatment. Chapter 6
summarizes some of the research that supports the use of BSFT with adolescents. The manual also has two
appendices, one on training counselors to implement BSFT and another presenting case examples from the
authors' work. Concepts and techniques discussed by Minuchin and Fishman (1981) have been adapted in
this BSFT manual for application to drug-abusing adolescents. Additional discussion of BSFT can be found
in Szapocznik and Kurtines (1989).
48

Chapter 2 - Basic Concepts of Brief Strategic Family Therapy
The previous chapter introduced the underlying philosophy of BSFT: to help families help themselves and
to preserve the family unit, whenever possible. The remainder of this manual focuses more directly on
BSFT as a strategy to treat adolescent drug abuse and its associated behavior problems. This chapter
presents the most basic concepts of the BSFT approach. It begins with a discussion of five theoretical
concepts that comprise the basic foundation of BSFT. Some of these concepts may be new for drug abuse
counselors. The five concepts discussed in this chapter are:
Context
Systems
Structure
Strategy
Content versus process
Context
The social influences an individual encounters have an important impact on his or her behavior. Such
influences are particularly powerful during the critical years of childhood and adolescence. The BSFT
approach asserts that the counselor will not be able to understand the adolescent's drug-abusing behavior
without understanding what is going on in the various contexts in which he or she lives. Drug-abusing
behavior does not happen in a vacuum; it exists within an environment that includes family, peers,
neighborhood, and the cultures that define the rules, values, and behaviors of the adolescent.
Family as Context
Context, as defined by Urie Bronfenbrenner (1977, 1979, 1986, 1988), includes a number of social contexts.
The most immediate are those that include the youth, such as family, peers, and neighborhoods.
Bronfenbrenner recognized the enormous influence the family has, and he suggested that the family is the
primary context in which the child learns and develops. More recent research has supported
Bronfenbrenner's contention that the family is the primary context for socializing children and adolescents
(for reviews, see Perrino et al. 2000; Szapocznik and Coatsworth 1999).
Peers as Context
Considerable research has demonstrated the influences that friends' attitudes, norms, and behaviors have on
adolescent drug abuse (Brook et al. 1999; Newcomb and Bentler 1989; Scheier and Newcomb 1991).
Moreover, drug-using adolescents often introduce their peers to and supply them with drugs (Bush et al.
1994). In the face of such powerful peer influences, it may seem that parents can do little to help their
adolescents.
However, recent research suggests that, even in the presence of drugusing (Steinberg et al. 1994) or
delinquent (Mason et al. 1994) peers, parents can wield considerable influence over their adolescents. Most
of the critical family issues (e.g., involvement, control, communication, rules and consequences, monitoring
and supervision, bonding, family cohesion, and family negativity) have an impact on how much influence
parents can have in countering the negative impact peers have on their adolescents' drug use.
Neighborhood as Context
The interactions between the family and the context in which the family lives may also be important to
consider. A family functions within a neighborhood context, family members live in a particular
neighborhood, and the children in the family are students at a particular school. For instance, to effectively
manage a troubled 15- year-old's behavioral problems in a particular neighborhood, families may have to
work against high drug availability, crime, and social isolation. In contrast, a small town in a semi-rural
community may have a community network that includes parents, teachers, grandparents, and civic leaders,
all of whom collaborate in raising the town's children. Neighborhood context, then, can introduce additional
challenges to parenting or resources that should be considered when working with families.
49

Culture as Context
Bronfenbrenner also suggested that families, peers, and neighborhoods exist within a wider cultural context
that influences the family and its individual members. Extensive research on culture and the family has
demonstrated that the family and the child are influenced by their cultural contexts (Santisteban et al. 2003;
Szapocznik and Kurtines 1993). Much of the researchers' work has examined the ways in which minority
families' values and behaviors have an impact on the relationship between parents and children and affect
adolescents' involvement with drug abuse and its associated problems (Santisteban et al. 2003; Szapocznik
and Kurtines 1980, 1993; Szapocznik et al. 1978).
Counseling as Context
The counseling situation itself is a context that is associated with a set of rules, expectations, and
experiences. The cultures of the client (i.e., the family), the counselor, the agency, and the funding source
can all affect the nature of counseling as can the client's feelings about how responsive the "system" is to his
or her needs.
Systems
Systems are a special case of context. A system is made up of parts that are interdependent and interrelated.
Families are systems that are made up of individuals (parts) who are responsive (interrelated) to each other's
behaviors.
A Whole Organism
"Systems" implies that the family must be viewed as a whole organism. In other words, it is much more than
merely the sum of the individuals or groups that it comprises. During the many years that a family is
together, family members develop habitual patterns of behavior after having repeated them thousands of
times. In this way, each individual member has become accustomed to act, react, and respond in a specific
manner within the family. Each member's actions elicit a certain reaction from another family member over
and over again over time. These repetitive sequences give the family its own form and style.
The patterns that develop in a family actually shape the behaviors and styles of each of its members. Each
family member has become accustomed to behaving in certain ways in the family. Basically, as one family
member develops certain behaviors, such as a responsible, take-control style, this shapes other family
members' behaviors. For example, family members may allow the responsible member to handle logistics.
At the same time, the rest of the family members may become less responsible. In this fashion, family
members complement rather than compete with one another. These behaviors have occurred so many times,
often without being thought about, that they have shaped the members to fit together like pieces of a puzzle-
-a perfect, predictable fit.
Family Systemic Influences
Family influences may be experienced as an "invisible force." Family members' behavior can vary
considerably. They may act much differently when they are with other family members than when they are
with people outside the family. By its very presence, the family system shapes the behaviors of its members.
The invisible forces (i.e., systemic influences) that govern the behaviors of family members are at work
every time the family is together. These "forces" include such things as spoken or unspoken expectations,
alliances, rules for managing conflicts, and implicitly or explicitly assigned roles.
In the case of an adolescent with behavior problems, the family's lack of skills to manage a misbehaving
youth can create a force (or pattern of interaction) that makes the adolescent inappropriately powerful in the
family. For example, when the adolescent dismisses repeated attempts by the parents to discipline him or
her, family members learn that the adolescent generally wins arguments, and they change their behavior
accordingly. Once a situation like this arises in which family expectations, alliances, rules, and so on have
been reinforced repeatedly, family members may be unable to change these patterns without outside help.
50

The Principle of Complementarity
The idea that family members are interdependent, influencing and being influenced by each other, is not
unique to BSFT. Using different terminology, the theoretical approach underlying behaviorally oriented
family treatments might explain these mutual influences as family members both serving as stimuli for and
eliciting responses from one another (Hayes et al. 1999). The theoretical approach underlying existential
family treatments might describe this influence as family members either supporting or constraining the
growth of other family members (Lantz and Gregoire 2000). What distinguishes BSFT from behaviorally
oriented and existential family treatments is its focus on the family system rather than on individual
functioning.
BSFT assumes that a drug-abusing adolescent will improve his or her behavior when the family learns how
to behave adaptively. This will happen because family members, who are "linked" emotionally, are
behaviorally responsive to each other's actions and reactions. In BSFT, the Principle of Complementarity
holds that for every action by a family member there is a corresponding reaction from the rest of the family.
For instance, often children may have learned to coerce parents into reinforcing their negative behavior--for
example, by throwing a temper tantrum and stopping only when the parents give in (Patterson 1982;
Patterson and Dishion 1985; Patterson et al. 1992). Only when the parents change their behavior and stop
reinforcing or "complementing" negative behavior will the child change.
Structure: Patterns of Family Interaction
An exchange among family members, either through actions or conversations, is called an interaction. In
time, interactions become habitual and repetitive, and thus are referred to as patterns of interaction
(Minuchin 1974). Patterns of family interaction are the habitual and repeated behaviors family members
engage in with each other. More specifically, the patterns of family interaction are comprised of linked
chains of behavior that occur among family members. A simple example can be illustrated by observing that
family members choose to sit at the same place at the dinner table every day. Where people sit may make it
easier for them to speak with each other and not with others. Consequently, a repetitive pattern of
interaction reflected in a "sitting" pattern is likely to predict the "talking" pattern. A large number of these
patterns of interaction will develop in any system. In families, this constellation of repetitive patterns of
interaction is called the family "structure."
The repetitive patterns of interaction that make up a family's structure function like a script for a play that
the actors have read, memorized, and re-enact constantly. When one actor says a certain line from the script
or performs a certain action, that is the cue for other actors to recite their particular lines or perform their
particular actions. The family's structure is the script for the family play.
Families of drug-abusing adolescents tend to have problems precisely because they continue to interact in
ways that allow the youths to misbehave. BSFT counselors see the interactions between family members as
maintaining or failing to correct problems, and so they make these interactions the targets of change in
therapy. The adaptiveness of an interaction is defined in terms of the degree to which it permits the family
to respond effectively to changing circumstances.
51

Strategy: The Three Ps of Effective Strategy
As its second word suggests, a fundamental concept of Brief Strategic Family Therapy is strategy. BSFT
interventions are strategic (Haley 1976) in that they are practical, problem-focused, and planned.
Practical
BSFT uses strategies that work quickly and effectively, even though they might seem unconventional.
BSFT may use any technique, approach, or strategy that will help change the maladaptive interactions that
contribute to or maintain the family's presenting problem. Some interventions used in BSFT may seem
"outside the theory" because they may be borrowed from other treatment modalities, such as behavior
modification. For example, behavioral contracting, in which patients sign a contract agreeing to do or not to
do certain things, is used frequently as part of BSFT because it is one way to re-establish the parent figures
as the family leaders. Frequently, the counselor's greatest challenge is to get the parent(s) to behave in a
measured and predictable fashion. Behavioral contracting may be an ideal tool to use to accomplish this.
The BSFT counselor uses whatever strategies are most likely to achieve the desired structural (i.e.,
interactional) changes with maximum speed, effectiveness, and permanence. Often, rather than trying to
capture every problematic aspect of a family, the BSFT counselor might emphasize one aspect because it
serves to move the counseling in a particular direction. For example, a counselor might emphasize a
mother's permissiveness because it is related to her daughter's drug abuse and not emphasize the mother's
relationship with her own parents, which may also be problematic.
Problem-Focused
The BSFT counselor works to change maladaptive interactions or to augment existing adaptive interactions
(i.e., when family members interact effectively with one another) that are directly related to the presenting
problem (e.g., adolescent drug use). This is a way of limiting the scope of treatment to those family
dynamics that directly influence the adolescent's symptoms. The counselor may realize that the family has
other problems. However, if they do not directly affect the adolescent's problem behaviors, these other
family problems may not become a part of the BSFT treatment. It is not that BSFT cannot focus on these
other problems. Rather, the counselor makes a choice about what problems to focus on as part of a timelimited
counseling program. For example, the absence of clear family rules about appropriate and
inappropriate behavior may directly affect the adolescent's drug-using behavior, but marital problems might
not need to be modified to help the parents increase their involvement, control, monitoring and supervision,
rule setting, and enforcement of rules in the adolescent's life.
Most families of drug-abusing adolescents are likely to experience multiple problems in addition to the
adolescent's symptoms. Frequently, counselors complain that "this family has so many problems that I don't
know where to start." In these cases, it is important for the counselor to carefully observe the distinction
between "content" and "process" (see "Content Versus Process: A Critical Distinction," p. 13). Normally,
families with many different problems (a multitude of contents) are unable to tackle one problem at a time
and keep working on it until it has been resolved (process). These families move (process) from one
problem to another (content) without being able to focus on a single problem long enough to resolve it. This
is precisely how they become overwhelmed with a large number of unresolved problems. It is their process,
or how they resolve problems, that is faulty. The counselor's job is to help the family keep working on
(process) a single problem (content) long enough to resolve it. In turn, the experience of resolving the
problem may help change the family's process so that family members can apply their newly acquired
resolution skills to other problems they are facing. If the counselor gets lost in the family's process of
shifting from one content/ problem to another, he or she may feel overwhelmed and, thus, be less likely to
help the family resolve its conflicts.
Planned
In BSFT, the counselor plans the overall counseling strategy and the strategy for each session. "Planned"
means that after the counselor determines what problematic interactions in the family are contributing to the
problem, he or she then makes a clear and well-organized plan to correct them.
52

Content Versus Process: A Critical Distinction
In BSFT, the "content" of therapy refers to what family members talk about, including their explanations for
family problems, beliefs about how problems should be managed, perspectives about who or what causes
the problems, and other topics. In contrast, the "process" of therapy refers to how family members interact,
including the degree to which family members listen to, support, interrupt, undermine, and express emotion
to one another, as well as other ways of interacting. The distinction between content and process is
absolutely critical to BSFT. To be able to identify repetitive patterns of interaction, it is essential that the
BSFT counselor focus on the process rather than the content of therapy.
Process is identified by the behaviors that are involved in a family interaction. Nonverbal behavior is
usually indicative of process as is the manner in which family members speak to one another.
Process and content can send contradictory messages. For example, while an adolescent may say, "Sure
Mom, I'll come home early," her sarcastic gesture and intonation may indicate that she has no intention of
following her mother's request that she be home early. Generally, the process is more reliable than the
content because behaviors or interactions (e.g., disobeying family rules) tend to repeat over time, while the
specific topic involved may change from interaction to interaction (e.g., coming home late, not doing
chores, etc.).
The focus of BSFT is to change the nature of those interactions that constitute the family's process. The
counselor who listens to the content and loses sight of the process won't be able to make the kinds of
changes in the family that are essential to BSFT work. Frequently, a family member will want to tell the
counselor a story about something that happened with another family member. Whenever the counselor
hears a story about another family member, the counselor is allowing the family to trap him or her in
content. If the counselor wants to refocus the session from content to process, when Mom says, "Let me tell
you what my son did...," the counselor would say: "Please tell your son directly so that I can hear how you
talk about this." When Mom talks to her son directly, the therapist can observe the process rather than just
hear the content when Mom tells the therapist what her son did. Observations like these will help the
therapist characterize the problematic interactions in the family.
53

Chapter 3 - Diagnosing Family System Problems
The BSFT approach to assessing and diagnosing family system problems differs drastically from that used
by other kinds of psychotherapies. Unlike other psychotherapies that assess and diagnose by focusing on
content, such as talking about a family's history, BSFT assesses and diagnoses by identifying the current
family process. BSFT focuses on the nature and characteristics of the interactions that occur in the family
and either help or hinder the family's attempts to get rid of the adolescent's problem behaviors.
The following six elements of the family's interactions are examined in detail:
Organization
Resonance
Developmental stages
Life context
Identified patient
Conflict resolution
Organization
As repetitive patterns of interaction in a family occur over time, they give the family a specific form, or
"organization." Three aspects of this organization are examined below: leadership, subsystem organization,
and communication flow.
Leadership
Leadership is defined as the distribution of authority and responsibility within the family. In functional twoparent
families, leadership is in the hands of the parents. In modern societies, both parents usually share
authority and decisionmaking. Frequently, in one-parent families, the parent shares some of the leadership
with an older child. The latter situation has the potential for creating problems. In the case of a single parent
living within an extended family framework, leadership may be shared with an uncle, aunt, or grandparent.
In assessing whether leadership is adaptive, BSFT counselors look at hierarchy, behavior control, and
guidance.
Counselors look at the hierarchy, or the way a family is ranked, to see who is in charge of leading the family
and who holds the family's positions of authority. BSFT assumes that the leadership should be with the
parent figures, with supporting roles assigned to older family members. Some leadership responsibilities can
be delegated to older children, as long as those responsibilities are not overly burdensome, are ageappropriate,
and are delegated by parent figures rather than usurped by the children. BSFT counselors look
at behavior control in the family to see who, if anyone, keeps order and doles out discipline in the family.
Effective behavior control typically means that the parents are in charge and the children are acting in
accordance with parental rules. Guidance refers to the teaching and mentoring functions in the family. BSFT
assesses whether these roles are filled by appropriate family members and whether the youngsters' needs for
guidance are being met.
Subsystem Organization
Families have both formal subsystems (e.g., spouses, siblings, grandparents, etc.) and informal subsystems
(e.g., the older women, the people who manage the money, the people who do the housekeeping, the people
who play chess). Important subsystems must have a certain degree of privacy and independence. BSFT
looks at issues such as the adequacy or appropriateness of the subsystems in a family. It also assesses the
nature of the relationships that give rise to these subsystems and especially looks at subsystem membership,
triangulation, and communication flow, which are discussed below.
Subsystem Membership
BSFT identifies the family's subsystems, which are small groups within the family that are composed of
family members with shared characteristics, such as age, gender, role, interests, or abilities. BSFT
counselors pay particular attention to the appropriateness of each subsystem's membership and to the
boundaries between subsystems. For example, parent figures should form a subsystem, while siblings of
similar ages should also form a subsystem, and each of these subsystems should be separate from the others.
54

Subsystems that cross generations (e.g., between a parent and one child) cause trouble because such
relationships blur hierarchical lines and undermine a parent's ability to control behavior. Relationships in
which one parent figure and a child unite against another parent figure are called "coalitions." Coalitions are
destructive to family functioning and are very frequently seen in families of drug-abusing adolescents. In
these cases, the adolescent has gained so much power through this relationship that he or she dares to
constantly challenge authority and gets away with it. The adolescent has this power to be rebellious,
disobedient, and out of control by having gained the support of one parent who, to disqualify the other
parent, enables the adolescent's inappropriate behavior.
Triangulation
Sometimes when two parental authority figures have a disagreement, rather than resolving the disagreement
between themselves, they involve a third, less powerful person to diffuse the conflict. This process is called
"triangulation." Invariably this triangulated third party, usually a child or an adolescent, experiences stress
and develops symptoms of this stress, such as behavior problems. Triangles always spell trouble because
they prevent the resolution of a conflict between two authority figures. The triangulated child typically
receives the brunt of much of his or her parents' unhappiness and begins to develop behavior problems that
should be understood as a call for help.
Communication Flow
The final category of organization looks at the nature of communication. In functional families,
communication flow is characterized by directness and specificity. Good communication flow is the ability
of two family members to directly and specifically tell each other what they want to say. For example, a
declaration such as, "I don't like it when you yell at me," is a sign of good communication because it is
specific and direct. Indirect communications are problematic. Take, for example, a father who says to his
son, "You tell your mother that she better get here right away," or the mother who tells the father, "You
better do something about Johnny because he won't listen to me." In these two examples, the
communication is conducted through a third person. Nonspecific communications are also troublesome, as
in the case of the father who tells his son, "You are always in trouble." The communication would be more
constructive if the father would explain very clearly what the problem is. For example: "I get angry when
you come home late."
Resonance
"Resonance" defines the emotional and psychological accessibility or distance between family members. A
6-year-old son who hangs onto his mother's skirt at his birthday party may be said to be overly close to her.
A mother who cries when her daughter hurts is emotionally very close. A father who does not care that his
son is in trouble with the law may be described as psychologically and emotionally distant.
One of the key concepts related to resonance is boundaries. An interpersonal boundary, just as the words
imply, is a way of denoting where one person or group of people ends and where the next one begins.
People set their own boundaries when they let others know which behaviors entering their personal space
they will allow and which ones they will not allow. In families, resonance refers to the psychological and
emotional closeness or distance between any two family members. This psychological and emotional
distance is established and maintained by the boundaries that exist between family members. In particular,
the boundaries between two family members determine how much affect, or emotion, can get through from
one person to the other. If the boundaries between two people are very permeable, then a lot gets through,
and there is high resonance-- great psychological and emotional closeness--between them. One's happiness
becomes the other's happiness. If the boundaries between two people are overly rigid, then each person may
not even know what the other is feeling.
Enmeshment and Disengagement
The firmness and clarity of boundaries reflect the degree of differentiation within a family system. At one
extreme, boundaries can be extremely impermeable. If this is the case, the emotional and psychological
distance between family members is too large, and these family members are said to be "disengaged" from
each other. At the other extreme, boundaries can be far too permeable or almost nonexistent. When
boundaries are that permeable, the emotional and psychological closeness between people is too great, and
these family members are said to be "enmeshed." Each of these extremes is problematic and becomes a
target for intervention.
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Interactions that are either enmeshed or disengaged can cause problems. When these interactions cause
problems, they need to be altered to establish a better balance between the closeness and distance that exists
between different family members. For each family, there is an ideal balance between closeness and
distance that allows cooperation and separation.
Resonance and Culture
Resonance needs to be assessed in the context of culture. This is important because some cultures encourage
family members to be very close with each other, while other cultures encourage greater distance. One
important aspect of culture involves the racial or ethnic groups with which families identify themselves. For
example, Hispanics are more likely than white Americans to be close and, thus, appear more enmeshed
(have higher resonance) (e.g., Woehrer 1989). Similarly, an Asian father may be quite distant or disengaged
from the women in his family, which is considered natural in his culture (Sue 1998). However, whether the
culture dictates the distance between family members, it is important for counselors to question if a
particular way of interacting is causing problems for the family. In other words, even if an interaction is
typical of a culture, if it is causing symptoms, then it may need to be changed. This type of situation must be
handled with great knowledge and sensitivity to demonstrate respect for the culture and to allow family
members to risk making a change that is foreign to their culture.
Enmeshment (high resonance) and Disengagement (low resonance)
Sometimes "enmeshment" (excessive closeness) and "disengagement" (excessive distance) can occur at the
same time within a single family. This happens frequently in families of drug-abusing youths, when one
parent is sometimes very protective and is closely allied with the youth (i.e., enabling), while the other
parent may be somewhat disinterested and distant.
BSFT counselors look for certain behaviors in a family that are telltale signs of either enmeshment or
disengagement. Obviously, some of these behaviors may happen in any family. However, when a large
number of these behaviors occur or when some occur in an extreme form, they are likely to reflect problems
in the family's patterns of interaction. Easily observable symptoms of enmeshment include one person
answering for another, one person finishing another's statements, and people interrupting each other.
Observable symptoms of disengagement include one family member who wants to be separated from
another or a family member who rarely speaks or is spoken about.
Developmental Stages
Individuals go through a series of developmental stages, ranging from infancy to old age. Certain
conditions, roles, and responsibilities typically occur at each stage. Families also go through a series of
developmental stages. For family members to continue to function adaptively at each developmental stage,
they need to behave in ways that are appropriate for the family's developmental level.
Each time a developmental transition is reached, the family is confronted by a new set of circumstances. As
the family attempts to adapt to the new circumstances, it experiences stress. Failure to adapt, to make the
transition, to give up behaviors that were used successfully at a previous developmental stage, and to
establish new behaviors that are adaptive to the new stage will cause some family members to develop new
behavior problems. Perhaps one of the most stressful developmental changes occurs when children reach
adolescence. This is the stage at which a large number of families are not able to adapt to developmental
changes (e.g., from direct guidance to leadership and negotiation). Parents must be able to continue to be
involved and monitor their adolescent's life, but now they must do it from a distinctly different perspective
that allows their daughter or son to gain autonomy.
At each developmental stage, certain roles and tasks are expected of different family members. One way to
determine whether the family has successfully overcome the various developmental challenges that it has
confronted is to assess the appropriateness of the roles and tasks that have been assigned to each family
member, considering the age and position of each person within the family.
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When a family's developmental stage is analyzed, four major sets of tasks and roles must be assessed:
(1) Parenting tasks and roles are concerned with the parent figures' ability to act as parents at a level
consistent with the age of the children;
(2) Marital tasks and roles assess how well spouses cooperate and share parenting functions;
(3) Sibling tasks and roles assess whether the children and adolescents are behaving in an age-appropriate
fashion; and
(4) Extended family's tasks and roles target the support for and intrusion into parenting functions from, for
example, grandparents, aunts, and uncles, if extended family members are part of the household or share in
parenting responsibilities.
Developmental transitions may be stressful. They are likely to cause family shake-ups because families may
continue to approach new situations in old ways, thus making it possible for conflict to develop. Most often,
families come to the attention of counselors precisely at these times. Of all of these developmental
milestones, reaching adolescence appears to be one of the most risky and critical stages in which drug abuse
can occur in most ethnic groups (Steinberg 1991; Vega and Gil 1999). Although the adolescent is the family
member who is most likely to behave in problematic ways, often other members of the family, such as
parents, also exhibit signs of troublesome or maladaptive behaviors and feelings (Silverberg 1996).
Assessing Appropriate Developmental Functioning
Careful judgments are needed to determine what is developmentally appropriate and/or inappropriate for
each family member. It is particularly difficult to make these judgments when assessing the tasks and roles
of children and extended family members. In every instance, the BSFT counselor should take into account
the family's cultural heritage when making these judgments. For example, it is useful to know that some
traditional African-American and Hispanic families tend to protect their children longer than non-Hispanic
whites do (White 1994). Thus, it would not be unusual for children to have a longer period of dependence
among traditional Hispanic groups than among non-Hispanic white families. Similarly, it would not be
unusual for the African-American caretaker of a 12-year-old to continue to behave in an authoritarian
manner without the child rebelling or considering it odd. In fact, researchers have suggested that African-
American inner city youths experience an authoritarian command as caring, while a child from another
cultural group might experience it as rejecting (Mason et al. 1994). However, as suggested earlier, as an
adolescent in the United States grows older, his or her parent, who may be from any culture and in any
setting, may have to moderate his or her level of control and increase his or her authoritative parenting, or
the youth may rebel.
Common Problems in Assessing Appropriateness of Developmental Stage
It is often difficult for parents to determine what is developmentally appropriate for children of different
ages; for example, how much or how little responsibility should a child 6, 10, or 16 years old have in a
household? In families of drug-abusing and conduct-disordered adolescents, parents and their children often
have a difficult time determining what is developmentally appropriate for a child's age.
One of the main problems family members encounter is how to determine the degree of supervision and
autonomy that children should have at each age level. This is a highly complex and conflictive area, even
for the best of parents, because as children grow older, they experience considerable pressure from their
peers to demonstrate increasing independence. It is also complex because many parents are not aware of
what might be the norm in today's society. Therefore, they may allow too little or too much autonomy,
based either on their own comfort or discomfort level, their own experience, and/or their culture. Moreover,
children's peer groups may vary considerably in the level of autonomy they expect from parents. In working
with the notion of "developmental appropriateness," a BSFT counselor needs to examine issues such as
roles and functions, rights and responsibilities, limits and consequences, as they are applied to the
adolescents in the family. Examples of these standards are available from adolescent development research
(Steinberg 1998).
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Life Context
While the dimensions of family functioning discussed up to now are all within the family, life context refers
to what happens in the family's relationship to its social context. The life context of the family includes the
extended family, the community, the work situation, adolescent peers, schools, courts, and other groups that
may have an impact on the family, either as stressors or as support systems.
Antisocial Peers
A careful analysis of the life context is useful in many situations involving the treatment of substance abuse.
For example, a youngster who uses drugs may be involved with a deviant or antisocial peer group. These
friendships affect the youth and family in an adverse way and will certainly need to be modified to
successfully eliminate the youth's drug use. Parents need help to identify less acceptable and more
acceptable adolescent peers so that they can encourage their teens to associate with more desirable peers and
discourage them from associating with less desirable peers.
Parent Support Systems and Social Resources
Parenting is a difficult task. Parents often lack adequate support systems for parenting. Parents need support
from friends, extended family members, and other parents (Henricson and Roker 2000). The availability of
support systems needs to be assessed, particularly in the case of single-parent families. The availability of
social resources needs to be assessed, both in terms of what is already being used or what could potentially
be used.
Juvenile Justice System
Increasingly, probation officers and the courts have become critical players in the families of drug-abusing
adolescents. It is the BSFT counselor's job to assess how juvenile justice representatives such as probation
officers interact with the family to determine whether they are supporting or undermining the family. One
way to assess the probation officer's role, for example, is to invite him or her to participate in a family
therapy session.
Identified Patient
The "identified patient" is the family member who has been branded by the family as the problem. The
family blames this person, usually the drug-abusing adolescent, for much of its troubles. However, as
discussed earlier, the BSFT view of the family is that the symptom is only that: a symptom of the family's
problems. The more that family members insist that their entire problem is embodied in a single person, the
more difficult it will be for them to accept that it is the entire family that needs to change. On the other
hand, the family that recognizes that several of its members may have problems is far healthier and more
flexible and will have a relatively easier time of making changes through BSFT. The BSFT counselor
believes that the problem is in the family's repetitive (habitual, rigid) patterns of interaction. Thus, the
counselor not only will try to change the person who exhibits the problem but also to change the way all
members of the family behave with each other.
The other aspect to understanding a family's identified patient is that usually families with problematic
behaviors identify only one aspect of the identified patient as the source of all the pain and worry. For
example, families of drug-abusing youths tend to focus only on the drug use and possibly on accompanying
school and legal troubles that are directly and overtly related to the drug abuse. These families usually
overlook the fact that the youngster may have other symptoms or problems, such as depression, attention
deficit disorder, and learning deficits.
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Conflict Resolution
While solving differences of opinion is always challenging, it is much more challenging when it is done in
the context of a conflictive relationship that is high in negativity. The following are five different ways in
which families can approach or manage conflicts. Some are adaptive and some are not. In the case of drugabusing
adolescents, with few exceptions, the first four tend to be ineffective, whereas the fifth tends to be
effective in most situations:
Denial
Denial
Avoidance
Diffusion
Conflict emergence without resolution
Conflict emergence with resolution
"Denial" refers to a situation in which conflict is not allowed to emerge. Sometimes this is done by adopting
the attitude that everything is all right. At other times, conflict is denied by arranging situations to avoid
confrontation or establishing unwritten rules with which no one dares to disagree outwardly, regardless of
how they feel. The classic denial case is the one in which the family says: "We have no problems."
Avoidance
"Avoidance" refers to a situation in which conflict begins to emerge but is stopped, covered up, or inhibited
in some way that prevents it from emerging. Examples of avoidance include postponing ("Let's not have a
fight now."), humor ("You're so cute when you're mad."), minimizing ("That's not really important."), and
inhibiting ("Let's not argue; you know what can happen.").
Diffusion
"Diffusion" refers to situations in which conflict begins to emerge, but discussion about the conflict is
diverted in another direction. This diversion prevents conflict resolution by distracting the family's attention
away from the original conflict. This change of subject is often framed as a personal attack against the
person who raised the original issue. For example, a mother says to her husband, "I don't like it when you
get home late," but the husband changes the topic by responding: "What kind of mother are you anyway,
letting your son stay home from school today when he is not even sick!"
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Conflict Emergence Without Resolution
"Conflict emergence" without resolution occurs when different opinions are clearly expressed, but no final
solution is accepted. Everyone knows exactly where everyone else stands, but little is done to reach a
negotiated agreement. Sometimes this occurs because the family, while willing to discuss the problem,
simply does not know how to negotiate a compromise.
Conflict Emergence With Resolution
Emergence of the conflict and its resolution is generally considered to be the best outcome. Separate
accounts and opinions regarding a particular conflict are clearly expressed and confronted. Then, the family
is able to negotiate a solution that is acceptable to all family members involved.
A Caveat
In some cases, conflicts need to be postponed for more appropriate times. For example, if a family member
is very angry, tired, or sick, it may be reasonable to table the conflict until he or she is ready to have a
meaningful discussion. However, in such instances, it is critical that the family set a specific time to address
the conflict. Indefinitely postponing conflict resolution is a sign of avoidance. A postponement for a definite
amount of time is adaptive.
In other instances, a person may decide that the issue at hand is not worth having an argument about. For
example, one person may want to stay home while his or her partner wants to go dancing. Either partner
may opt to compromise by agreeing to the other's preference. So long as partners take turns compromising,
this is adaptive and balanced. However, if the same person is always the one to give in, this may reflect the
use of denial by one partner to avoid conflict with the other.
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Chapter 4 - Orchestrating Change
This chapter describes the BSFT approach to orchestrating change in the family. The first section describes
how BSFT counselors establish a therapeutic relationship, including the importance of joining with the
family, the role of tracking family interactions, and what is involved in building a treatment plan. The
second section describes strategies for producing change in the family, including focusing on the present,
reframing negativity in the family, shifting patterns of interaction through reversals of usual behavior,
changing family boundaries and alliances, "detriangulating" family members caught in the middle of others'
conflicts, and opening up closed family systems or subsystems by directing new interactions.
Establishing a Therapeutic Relationship
The counselor's first step in working with a family is to establish a therapeutic relationship with the family,
beginning with the very first contact with family members. The quality of the relationship between the
counselor and the family is a strong predictor of whether families will come to, stay in, and improve in
treatment (Robbins et al. 1998). In general, studies have found that the therapeutic relationship is a strong
predictor of success in many forms of therapy (Rector et al. 1999; Stiles et al. 1998). Validating and
supporting the family as a system and attending to each individual family member's experience are
particularly important aspects of developing and maintaining a good therapeutic relationship (Diamond et
al. 1999; Diamond and Liddle 1996).
Establishing a therapeutic relationship means that the BSFT counselor needs to form a new system--a
therapeutic system--made up of the counselor and the family. In this therapeutic system, the counselor is
both a member and its leader. One challenge for the BSFT counselor is to establish relationships with all
family members, some of whom are likely to be in conflict with each other. For example, drug-abusing
adolescents generally begin treatment in conflict with their parent(s) or guardian(s). Both parties approach
counseling needing support from the counselor. The counselor's job is to find ways to support the
individuals on either side of the conflict. For example, the counselor might say to the adolescent, "I am here
to help you explain to your something he or she would like to achieve, the counselor is able to establish a
therapeutic alliance with the whole family.
The BSFT approach is based on the view that building a good therapeutic relationship is necessary to bring
about change in the family. Several strategies for building a therapeutic relationship, joining, tracking, and
building a treatment plan, are discussed below.
Joining
A number of techniques can be used to establish a therapeutic relationship. Some of these techniques fall
into the category of "joining," or becoming a temporary member of the family.
Definition of Joining
In BSFT, joining has two aspects. Joining it is the steps a counselor takes to prepare the family for change.
Joining also occurs when a therapist gains a position of leadership within the family. Counselors use a
number of techniques to prepare the family to accept therapy and to accept the therapist as a leader of
change. Some techniques that the therapist can use to facilitate the family's readiness for therapy include
presenting oneself as an ally, appealing to family members with the greatest dominance over the family unit,
and attempting to fit in with the family by adopting the family's manner of speaking and behaving. A
counselor has joined a family when he or she has been accepted as a "special temporary member" of the
family for the purpose of treatment. Joining occurs when the therapist has gained the family's trust and has
blended with family members. To prepare the family for change and earn a position of leadership, the
counselor must show respect and support for each family member and, in turn, earn each one's trust.
One of the most useful strategies a counselor can employ in joining is to support the existing family power
structure. The BSFT counselor supports those family members who are in power by showing respect for
them. This is done because they are the ones with the power to accept the counselor into the family; they
have the power to place the counselor in a leadership role, and they have the power to take the family out of
counseling. In most families, the most powerful member needs to agree to a change in the family, including
changing himself or herself. For that reason, the counselor's strongest alliance must initially be with the
most powerful family member. BSFT counselors must be careful not to defy those in power too early in the
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process of establishing a therapeutic relationship. Inexperienced family counselors often take the side of one
family member against another, behaving as though one were right and the other were obviously wrong. In
establishing relationships with the family, the counselor must join all family members, not just those with
whom he or she agrees. In fact, frequently, the person with whom it is most critical to establish an alliance
or bond is the most powerful and unlikable family member.
Many counselors in the drug abuse field feel somewhat hopeless about helping the families of drug-abusing
youths because these families have many serious problems. Counselors who feel this way may find a
discussion about becoming a member of the family unhelpful because their previous efforts to change
families have been unsuccessful. BSFT teaches counselors how to succeed by approaching families as
insiders, not as outsiders. As outsiders, counselors typically attempt to force change on the family, often
through confrontation. However, the counselor who has learned how to become part of the system and to
work with families from the inside should seldom need to be confrontational. Confrontation erodes the
rapport and trust that the counselor has worked hard to earn. Confrontation can change the family's
perception of the counselor as being an integral part of the therapeutic system to being an outsider.
The Price of Failed Joining
An example may help illustrate what is meant by powerful family members. The court system referred a
family to counseling because its oldest child had behavior problems. The mother was willing to come to
counseling with her son, but the mother's live-in boyfriend did not want the family to be in counseling. The
counselor advised the mother to come to therapy with the adolescent anyway. The boyfriend felt that his
position of power had been threatened by the potential alliance between the mother and the counselor. As a
result, the boyfriend reasserted himself, demanding that she stop participating in counseling. She then
dropped out of counseling. This is clearly a case in which the counselor's early challenge of the family's way
of "operating" caused the entire family to drop out of treatment. The counselor could and should have been
more aware and respectful of the family's existing power structure. Respect, in this case, does not mean that
the counselor approves of or agrees with the boyfriend's behavior. Rather, it means that the counselor
understands how this family is organized and works his or her way into the family through the existing
structure.
A more adaptive counseling strategy might be to call the mother's boyfriend, with the mother's permission,
to recognize his position of power in the family and request his help with his girlfriend's son.
A Cautionary Note: Family Secrets
As was already stated, joining is about establishing a relationship with every member of the family.
Sometimes a family member will try to sabotage the joining process by using family secrets. Some secrets
can cause the counselor such serious problems that he or she is forced to refer the family he or she had
intended to help to another counselor. Secrets are best dealt with up front. The counselor should not allow
himself or herself to get trapped in a special relationship with one family member that is based on sharing a
secret that the other family members do not know. A counselor who keeps a secret is caught between family
members. The counselor has formed an alliance with one family member to the exclusion of others. In some
cases, it is not just an alliance with one family member but also an alliance with one family member against
another family member. It means that the family member with the secret can blackmail the counselor with
the threat of revealing that the counselor knows this secret and didn't address it with the family.
Consequently, a family secret is a very effective strategy that family members can use to sabotage the
treatment, if counselors let them.
For these reasons, counselors should make it a rule to announce to each family at the onset of counseling
that he or she will not keep secrets. The counselor should also say that if anyone shares special information
with the counselor, the counselor will help them share it with the appropriate people in the family. For
example, if a wife calls and tells the counselor that she is having an affair, her spouse will need to know,
although the children do not need to know the parents' marital issues. In this case, the counselor would say,
"This affair is indicative of a problem in your marriage. Let me help you share it with your husband." The
counselor must do whatever is needed to continue to help the wife see that affairs are symptoms of marital
problems. The affair can be reframed as a cry for help, a call for action, or a basic discontent. If so, these
marital issues or problems need to be discussed.
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It is possible that despite all the counselor's efforts, the wife will respond with an absolute, "No, I don't want
to tell him. He would leave me. Besides, this affair doesn't mean all that much." Typically BSFT therapy
only gets into marital issues to the extent that the marital problems are interfering with the parents' abilities
to function effectively as parents. However, the counselor has no choice but to help the wife tell her
husband about the affair. If the wife absolutely refuses, then the counselor has lost his or her bid for
leadership in the counseling process. The wife now has control over the counseling process. For that reason,
the counselor must refer the family to another counselor.
Tracking
In the example on p. 27 about the mother's powerful boyfriend, it was recommended that the counselor use
the way in which the family is organized, or interacts, with the father figure in a position of power, as a
vehicle for getting the family into treatment. This strategy in which the counselor learns how the family
interacts and then uses this information to establish a therapeutic plan of action is called "tracking."
Tracking is a technique in which the counselor respects how the family interacts but, at the same time, takes
advantage of those family interactions for therapeutic purposes. Sometimes families interact spontaneously,
permitting the counselor to observe the family dynamics. When this does not happen spontaneously, the
counselor must encourage the family to interact.
Encouraging the Family to Interact
When a family is in counseling, family members like to tell the counselor stories about each other. For
example, a mother might say to the counselor, "My son did so and so." In contrast to the way in which the
counselor functions in other therapy models, the BSFT counselor is not interested in the content of the
family members' stories. Instead, the counselor is interested in observing (and correcting) problematic
interactions. To observe the family's patterns of interaction, the counselor must ask family members to talk
directly to each other about the problem. When this occurs, the counselor can observe or track what happens
when the family members discuss the issue. The counselor can then watch the family's interactions:
fighting, disagreeing, and struggling with their issues. By tracking, the counselor will not only be able to
identify the interactive patterns in the family, but also will be able to determine which of these patterns may
be causing the family's problems or symptoms. The added benefit of this kind of tracking is that the
counselor shows respect for the family's ways of interacting.
Tracking Content and Process
The difference between "content" and "process" was discussed in Chapter 2 (see p. 13). Content is the
subject matter that is being discussed. Process refers to the interactions that underlie the communication. By
observing the process, the counselor learns who is dominant, who is submissive, what emotions are
expressed in the interaction, and the unwritten rules that appear to guide the family's communication and
organization. For example, a mother may mention that her son's drug problem is a concern. The
grandmother responds by shouting that the mother is overreacting and needs to back off. The content of the
interaction--the son's drug problem--is not nearly as important as the process being displayed--the
grandmother undermining the mother and shutting her down. Often the counselor will track or use the
family's content because it represents a topic that is important to the family. In this example, the counselor
might keep the focus of the counseling session on the son's drug problem because it is an important topic in
this family. However, the focus of BSFT is entirely on changing process. What needs to be changed here, as
a first step, is the parent figures' inability to agree on the existence of a problem, and, more generally, the
grandmother's tendency to invalidate the mother's concerns.
Mimesis
"Mimesis" is a form of tracking for the purpose of joining. It refers to mimicking the family's behavior in an
effort to join with the family. Mimesis can be used to join with the whole family. For example, a counselor
can act jovial with a jovial family. Mimesis also can be used to join with one family member. Mimesis is
used in everyday social situations. For example, by attending to how others dress for a particular activity so
that one can dress appropriately, one is attempting to gain and demonstrate acceptance by mimicking the
type of dress that is worn by others (e.g., casual). People mimic other people's moods when they act like the
other people do in certain situations. For example, at a funeral they would act sad as others do and at a
celebration they would act joyful. When the counselor validates a family by mimicking its behavior, family
members are more likely to accept the counselor as one of their own.
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Mimesis also refers to using a family's own ways of speaking to join with the family. Each family and each
family member has its, his, or her own vocabulary and perspective. For instance, if a family member is a
carpenter, it might be useful to use the language of carpentry. The therapist might say, "Dealing with your
son requires lots of different tools, just like jobs at work do. Sometimes you need to use a hammer and use a
lot of force, and sometimes you need to use a soft cloth for a more gentle job." If a family member is an
accountant, it may be helpful to speak in terms of assets and liabilities. If a person is religious, it may be
helpful to speak of God's will.
Whatever language a family uses should be the language the counselor uses to converse with that family.
The counselor should not talk to a family using vocabulary that is found in this manual--words such as
"interactions," "restructuring," and "systems." Instead, the BSFT counselor should use the "pots and pans"
language that each of the family members uses in his or her everyday life. For example, if families are
uncomfortable with the term "counseling," the term "meetings" might be used.
Much of the work the counselor does to establish the therapeutic relationship involves learning how the
family interacts to better blend with the family. However, the counselor cannot learn the ways in which the
family interacts unless he or she sees family members interacting as they would when the counselor is not
present. Getting family members to interact can be difficult because families often come into counseling
thinking that their job is to tell the counselor what happened. Therefore, it is essential that counselors
decentralize themselves by discouraging communications that are directed at them, and instead encouraging
family members to interact so that they can be observed behaving in their usual way.
Building a Treatment Plan
BSFT diagnoses are made to identify adaptive and maladaptive patterns of family interaction so that the
counselor can plan practical, strategically efficient interventions. The purpose of the intervention is to
improve the family interactions most closely linked to the adolescent's symptoms. This, in turn, will help the
family to manage those symptoms.
Enactment: Identifying Maladaptive Interactions
In BSFT, the counselor assesses and diagnoses the family's interactions by allowing the family to interact in
the counseling session as it normally does at home. To begin, the counselor asks the family to discuss
something. When a family member speaks to the counselor about another family member who is present,
the counselor asks the family member who is speaking to repeat what was said directly to the family
member about whom it was said. Family interactions that occur as they would at home and that show the
family's typical interactional patterns are called "enactments." An enactment can either occur spontaneously,
or the counselor can initiate it by asking family members to discuss something among themselves. Creating
enactments of family interactions is like placing the counselor on the viewing side of a oneway mirror and
letting the family "do its thing" while the counselor observes.
Different therapy models have different explanations for why a family or adolescent is having difficulty,
and so they have different targets of intervention. BSFT targets interactional patterns. Because BSFT is a
problem-focused therapy approach, it targets those interactional patterns that are most directly related to the
symptom for which the family is seeking treatment. Targeting patterns most directly related to the symptom
allows BSFT to be brief and strengthens a therapist's relationship with a family by demonstrating that the
therapist will help the family solve the problems family members have identified.
Families that develop symptoms tend to be organized or to function around those symptoms. That's because
a symptom works like a magnet, organizing the family around it. This is especially true if the symptom is a
serious, life-threatening one, such as drug abuse. Therefore, it is most efficient to work with the family by
focusing on the symptom around which the family has already organized itself.
Family Crises as Enactments
Enactments are used to observe family interactions in the present and to identify family interactional
problems. Family crises are particularly opportune types of enactments because they are highly charged, and
family members are emotionally available to try new behaviors. Therefore, families in crisis should be seen
immediately. In addition to gaining valuable information about problematic family interactions, the
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counselor gains considerable rapport with families because he or she is willing to be of service at a time of
great need.
A Cautionary Note: Adolescents Attending Therapy Sessions on Drugs
Counselors usually refuse to work with a client who comes into the therapy session on drugs because the
client is viewed as "not being all there" to do the treatment work. However, in the case of a family therapy
such as BSFT, determining whether to conduct the session is a strategic decision the counselor must make.
One possibility in BSFT is to view the adolescent on drugs as an enactment of what the family confronts at
home all the time. Thus, when an adolescent comes to therapy on drugs, it can be viewed as an opportunity
for the counselor to teach the family how to respond to the adolescent when he or she takes drugs. The
BSFT counselor can see how each family member responds to this situation and look for the maladaptive
interactions that allow the adolescent to continue this behavior. The counselor can then work with the nondrug-using
family members to change their usual way of responding to the adolescent on drugs. Hence, the
work in this session is not with the adolescent but with the other family members.
From Diagnosis to Planning
Once a therapeutic relationship has been established and a diagnosis has been formulated, the counselor is
ready to develop a treatment plan. The treatment plan lays out the interventions that will be necessary to
change those family maladaptive interactional patterns that have been identified as related to the presenting
symptom. Problematic patterns of family interaction are diagnosed using the six dimensions of family
interaction discussed in Chapter 3 (organization, resonance, developmental stages, life context, identified
patient, and conflict resolution). Often some dimensions are more problematic than others. The
interventions need to focus more on the most problematic interactions than on the others.
The six dimensions of the family's interactions operate in an interdependent fashion. For this reason, it may
not be necessary to plan a separate intervention to address each problem that has been diagnosed. For
example, addressing a family's tendency to blame its problems on the adolescent (i.e., the identified patient)
may bring the family's ineffective conflict resolution strategies to light. In a similar fashion, addressing a
son's role as his mother's confidant (i.e., inappropriate developmental stage) may bring out the rigid and
inflexible boundary between the parent figures.
Producing Change
As was stated earlier, the focus of BSFT is to shift the family from maladaptive patterns of interaction to
adaptive ones. Counselors can use a number of techniques to facilitate this shift. These techniques, all of
which are used to encourage family members to behave differently, fall under the heading of
"restructuring." In restructuring, the counselor orchestrates and directs change in the family's patterns of
interaction (i.e., structure). Some of the most frequently used restructuring techniques are described in this
chapter.
When the family's structure has been shifted from maladaptive toward adaptive, the family develops a
mastery of communication and management skills. In turn, this mastery will help them solve both present
and future problems. To help family members master these skills, the BSFT counselor works with them to
develop new behaviors and use these new behaviors to interact more constructively with one another. After
these more adaptive behaviors and interactions occur, the BSFT counselor validates them with positive
reinforcements. Subsequently, the counselor gives the family the task of practicing these new
behaviors/interactions in naturally occurring situations (e.g., when setting a curfew or when eating meals
together) so that family members can practice mastering these skills at home.
Mastering more adaptive interactions provides families with the tools they need to manage the adolescent's
drug abuse and related problem behaviors. Some adaptive behaviors/interactions that validate individual
family members are self-reinforcing. However, the counselor needs to reinforce those behaviors/interactions
that initially are not strongly self-reinforcing (i.e., validated) to better ensure their sustainability. As family
members reinforce each other's more adaptive skills, they master the skills needed to behave in adaptive
ways. It is very important to note that mastery of adaptive skills is not achieved by criticizing, interpreting,
or belittling the individual. Rather, it is achieved by incrementally shaping positive behavior.
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Seven Frequently Used Restructuring Techniques
The rest of this chapter describes seven frequently used restructuring techniques (i.e., to change families'
patterns of interaction). These techniques will give a counselor the basic tools needed to help a family
change its patterns of interaction. The seven restructuring techniques are:
1. Working in the present
2. Reframing negativity
3. Reversals
4. Working with boundaries and alliances
5. Detriangulation
6. Opening up closed systems
7. Tasks
8. Working in the Present
Although some types of counseling focus on the past (Bergin and Garfield 1994), BSFT focuses strictly on
the present. In BSFT, families do not simply talk about their problems, because talking about problems
usually involves telling a story about the past. Working in the present with family interactional processes
that are maintaining the family's symptoms is necessary to bring about change in BSFT. Consequently, the
BSFT counselor wants the family to engage in interactions within the therapy session--in the same way that
it would at home. When this happens and family members enact the way in which they interact routinely,
the counselor can respond to help the family members reshape their behavior. Several techniques that
require working in the present with family processes are found in subsequent sections within this chapter.
1. Working in the present
Does BSFT Ever Work in the Past?
Counselors work with the past less than 5 percent of the counseling time. One important example of
working in the past can be illustrated by an early counseling session in which the parent and adolescent are
in adversarial roles. The parent may be angry or deeply hurt by the youth's behavior. One strategy to
overcome this impasse in which neither family member is willing to bend is to ask the parent, "Can you
remember when Felix was born? How did you feel?" The parent may say nostalgically: "He was such a
beautiful child. The minute I saw him, I was enchanted. I loved him so much I thought my heart would
burst."
This kind of intervention is called "reconnection" (cf. Liddle 1994, 1995, 2000). When the parent is
hardened by the very difficult experiences he or she has had with a troublesome adolescent, counselors
sometimes use the strategy of reconnection to overcome the impasse in which neither the parent nor the
youth is willing to bend first. Reconnection is an intervention that helps the parent recall the positive feeling
(love) that he or she once had for the child. After the parent expresses his or her early love for the child, the
counselor turns to the youth and says: "Did you know your mother loves you so very much? Look at the
expression of bliss on her face."
As can be seen, the counseling session digressed into the past for a very short time to reconnect the parent.
This was necessary to change the here-and-now interaction between two family members. The reconnection
allowed the counselor to transform an interaction characterized by resentment into an interaction
characterized by affection. Because the feelings of affection and bonding do not last long, the counselor
must move quickly to use reconnection as a bridge that moves the counseling to a more positive
interactional terrain.
2. Reframing: Systemic Cognitive Restructuring
To "reframe," a counselor creates a different perspective or "frame" of reality than the one within which the
family has been operating. He or she presents this new frame to the family in a convincing manner --that is,
"selling" it to the family and then using this new frame to facilitate change. The purpose of systemsoriented,
cognitive restructuring (reframing) is to change perceptions and/or meaning in ways that will
enable family members to change their interactions. Most of the time, in families of adolescent drug
abusers, negativity needs to be reframed. Negativity is usually exhibited as blaming, pejorative, and
invalidating statements ("You are no good." "I can't trust you."), and, in general, "angry fighting."
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Reframing negativity might involve describing a mother's criticism of her teenage son as her desire that he
be successful, or reframing fighting as an attempt to have some sort of connection with another family
member.
It has been suggested that "... high levels of negativity interfere with effective problem-solving and
communication within the family" (Robbins et al. 1998, p. 174). Robbins and colleagues report that
negativity in family therapy sessions is linked to dropping out of family therapy. For those who remain in
therapy, negativity is linked to poor family therapy outcomes. Because negativity is bad for the family and
for the therapy, most contemporary family therapies target negativity (Alexander et al. 1994). The bestknown
strategy for transforming negative interactions into positive ones is reframing (Robbins et al. 2000).
While the counselor is encouraged to permit family members to interact with each other in their usual way
and to join before orchestrating change, a caveat is necessary when intense negative feelings accompany
conflictive interactions. If the family is to remain in counseling, family members must experience some
relief from the negative feelings soon after counseling begins. Therefore, counselors are encouraged to use
reframing abundantly, if necessary, in the first and perhaps the first few sessions to alleviate the family's
intensive negative feelings. Such reframes also may allow family members to discuss their pain and
grievances in a meaningful way.
An example will help illustrate the use of reframing negative feelings to create more positive feelings
among family members. Anger is a fairly common emotion among families with an adolescent who is
involved in antisocial activities. The parents may feel angry that their attempts to guide their child down the
"right" path have failed and that the child disrespects their guidance. The adolescent is likely to interpret this
anger as uncaring and rejecting. Both parties may feel that the other is an adversary, which severely
diminishes the possibility that they can have a genuine dialogue.
The particular reframe that needs to be used is one that changes the emotions from anger, hurt, and fighting
(negative) to caring and concern (positive). The counselor must create a more positive reality or frame. The
counselor, for example, might say to the parent, "I can see how terribly worried you are about your son. I
know you care an awful lot about him, and that is why you are so frustrated about what he is doing to
himself."
With this intervention, the counselor helps move both the parent's and the child's perceptions from anger to
concern. Typically, most parents would respond by saying, "I am very worried. I want my child to do well
and to be successful in life." When the youth hears the parent's concern, he or she may begin to feel less
rejected. Instead of rejecting, the parent is now communicating concern, care, and support for the child.
Hence, by creating a more positive sense of reality, the counselor transforms an adversarial relationship
between the parent(s) and the adolescent, orchestrating opportunities for new channels of communication to
emerge and for new interactions to take place between them.
Reframing is among the safest interventions in BSFT, and, consequently, the beginning counselor is
encouraged to use it abundantly. Reframing is an intervention that usually does not cause the counselor any
loss of rapport. For that reason, the counselor should feel free to use it abundantly, particularly in the most
explosive situations.
Affect: Creating Opportunities for New Ways of Behaving
In BSFT, counselors are interested in affect (a feeling or an emotion) as it is reflected in interactions. In
BSFT, the counseling strategy is to use emotion as an opportunity to "move" the family to a new, more
adaptive set of interactions. One of many possible ways of working with emotion is found in the following
example. When a mother cries, the counselor might suggest to the drug-abusing youngster, "Ask your mom
to tell you about her tears." An alternative would be, "What do you think your mom's tears are trying to
say?" If the youth responds, "I think it is...," the counselor would follow with a directive to the youth, "Ask
your mother if what you think her tears mean is why she is crying." In this way, the crying is used to initiate
an interaction among family members that acknowledges not only the emotion in crying but also the
experience underlying the crying. In other words, the crying is used to promote interactions that show
respect for the emotion as well as promote a deeper level of understanding among family members.
In another example, a drug-abusing adolescent and her family come to their first BSFT counseling session.
The parents proceed to describe their daughter as disobedient, rebellious, and disrespectful-- a girl who is
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uining her life and going nowhere. They are angry and reject this young girl, and they blame her for all the
pain in the family. In this instance, the BSFT counselor recognizes that the family is "stuck" about what to
do with this girl and that their inability to decide what to do is based on the view they have developed about
her and her behavior. To "open up" the family to try new ways to reach the youngster, the BSFT counselor
must present a new "frame" or perspective that will enable the family to react differently toward the girl.
The BSFT counselor might tell the family that, although she realizes how frustrated and exasperated they
must feel about their daughter's behavior, "it is my professional opinion that the main problem with this girl
is that she is very depressed and is in a lot of pain that she does not know how to handle." Reframing is a
practical tool used to stimulate a change in family interactions. With this new frame, the family may now be
able to behave in new ways toward the adolescent, which can include communicating in a caring and
nurturing manner. A more collaborative set of relationships within the family will make it easier for the
parents to discuss the daughter's drug abuse, to address the issues that may be driving her to abuse drugs,
and to develop a family strategy to help the adolescent reduce her drug use.
3. Reversals
When using the technique called "reversal," the counselor changes a habitual pattern of interacting by
coaching one member of the family to do or say the opposite of what he or she usually would. Reversing the
established interactional pattern breaks up previously rigid patterns of interacting that give rise to and
maintain symptoms, while allowing alternatives to emerge. If an adolescent gets angry because her father
nagged her, she yells at her father, and the father and daughter begin to fight, a reversal would entail
coaching the father to respond differently to his daughter by saying, "Rachel, I love you when you get angry
like that," or "Rachel, I get very frightened when you get angry like that." Reversals make family members
interact differently than they did when the family got into trouble.
4. Working With Boundaries and Alliances
Certain alliances are likely to be adaptive. For example, when the authority or parent figures in the family
are allied with each other, they will be in a better position to manage the adolescent's problem behaviors.
However, when an alliance forms between a parent figure and one of the children against another parent
figure, the family is likely to experience trouble, especially with antisocial adolescent behavior. An
adolescent who is allied with an authority figure has a great deal of power and authority within the family
system. Therefore, it would be difficult to place limits on this adolescent's problem behavior. One goal of
BSFT is to realign maladaptive alliances.
One important determinant of alliances between family members is the psychological barrier between them,
or the metaphorical fence that distinguishes one member from another. BSFT counselors call this barrier or
fence a "boundary." Counselors aim to have clear boundaries between family members so that there is some
privacy and some independence from other family members. However, these should not be rigid boundaries,
with which family members would have few shared experiences. By shifting boundaries, BSFT counselors
change maladaptive alliances across the generations (e.g., between parent figures and child). For example,
in a family in which the mother and the daughter are allied and support each other on almost all issues while
excluding the father, the mother may no longer be powerful enough to control her daughter when she
becomes an adolescent and may need help. In this case, an alliance between the mother and the father needs
to be re-established, while the cross-generational coalition between mother and daughter needs to be
eliminated.
It is the BSFT counselor's job to shift the alliances that exist in the family. This means restoring the balance
of power to the parents or parent figures so that they can effectively exercise their leadership in the family
and control their daughter's behavior. The counselor attempts to achieve these alliance shifts in a very
smooth, subtle, and perhaps even sly fashion. Rather than directly confronting the alliance of the mother and
daughter, for example, the counselor may begin by encouraging the father to establish some form of
interaction with his daughter.
Boundary shifting is accomplished in two ways. Some boundaries need to be loosened, while others need to
be strengthened. Loosening boundaries brings disengaged family members (e.g., father and daughter) closer
together. This may involve finding areas of common interest between them and encouraging them to pursue
these interests together. For instance, in the case of a teenaged son enmeshed with his mother and
disengaged from his father, the counselor may direct the father to involve his son in a project or to take his
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son on regular outings. The counselor also may arrange the seating in counseling sessions to help strengthen
some alliances and loosen others.
In addition to bringing family members closer together, the counselor may need to strengthen the
boundaries between enmeshed family members to create more separation. One example is the
mothergrandmother parenting system in which the grandmother enables her grandson's drug use by
protecting him from his mother's attempts to set limits. Rather than confronting the grandmother-adolescent
alliance directly, the counselor may first encourage the mother and grandmother to sit down together and
design a set of rules and responsibilities for the adolescent. This process of designing rules often requires
the parent figures to work out some of the unresolved conflict(s) in their relationship, without the counselor
having to address that relationship directly. This brings the mother closer to the grandmother and distances
the grandmother from the adolescent, thereby rearranging the family's maladaptive hierarchy and subsystem
composition.
It should be noted that, in this case, the counselor tracks the family's content (grandmother hiding
adolescent's drug use from mother) as a maneuver to change the nature of the interaction between the
mother and the grandmother from an adversarial relationship to one in which they agree on something. The
adolescent's drug use provides the content necessary to strengthen the boundaries between the generations
and to loosen the boundaries between the parent figures.
Clearly, bringing the mother and grandmother together to the negotiating table is only an intermediate step.
After that, the tough work of helping mother and grandmother negotiate their deep-seated resentments and
grievances against each other begins. Because the counselor follows a problem-focused approach, he or she
does not attempt to resolve all of the problems the parent figures encounter. Instead, the counselor tries to
resolve only those aspects of their difficulties with each other that interfere with their ability to resolve the
problems they have with the adolescent in the family.
Behavioral Contracting as a Strategy for Setting Limits for Both Parent and Adolescent
From a process perspective, setting clear rules and consequences helps develop the demarcation of
boundaries between parent(s) and child(ren). Sometimes when a parent and an adolescent have a very
intense conflictive relationship in which there is a constant battle over the violation of rules, the rules and
their consequences are vague, and there is considerable lack of consistency in their application. In these
cases, it is recommended that the counselor use behavioral contracting to help the parent(s) and the
adolescent agree on a set of rules and the resulting consequences if he or she fails to follow these rules. The
counselor encourages the parent(s) and the adolescent to negotiate a set of clearly stated and enforceable
rules, and encourages both parties to commit to maintaining and following these rules.
Helping parents use behavioral contracting to establish boundaries for themselves in relationship to their
adolescent is of tremendous therapeutic value. Parents who have established boundaries can no longer
respond to the adolescent's behavior/misbehavior according to how they feel at the time (lax, tired,
frustrated, angry). The parents have committed themselves to respond according to agreed-upon rules. From
a BSFT point of view, it is very important for the counselor to begin to help the parents develop adequate
boundaries with their adolescent children who have behavior problems.
In families that have problems with boundaries, the counselor's most difficult task is to get the parents to
stick to their part of the contract. Counselors expect that the adolescent will not keep his or her part of the
contract and instead will try to test whether his or her parents will try to stick to their part of the contract.
When the adolescent misbehaves, parents tend to behave in their usual way, which may be a reaction to the
way they feel at the moment. The counselor's job is to make the parents uphold their side of the agreement.
Once parents have set effective boundaries with their adolescent children, most misbehavior quickly
diminishes. (Of course, sometimes rules and consequences need to be renegotiated as parents and
adolescents begin to acquire experience with the notion of enforceable rules and consequences.)
Boundaries Between the Family and the Outside World
It is important not only to understand the nature of the alliances and boundaries that occur within the family
but also to understand the boundaries that exist between the family and the outside world. (See Chapter 3, p.
21 on life context.)
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Some families have very rigid boundaries around themselves, prohibiting their members from interacting
with the outside world. Other families have very weak boundaries around themselves that allow outsiders to
have an undue influence on family members. Either of these extremes can be problematic and is fair ground
for BSFT intervention. For example, if parents are uninvolved with their children's school or friends (rigid
boundaries), the BSFT counselor works to get the parents to participate more fully in their child's school life
and to interact more with their child's friends.
5. Detriangulation
As was said earlier, triangles occur when a third, usually less powerful, person gets involved in a conflict
between two others. It is a basic assumption of BSFT that the only way conflict between two people (called
a "dyad") can be resolved is by keeping the conflict between them. Bringing in a third person and forming a
triangle becomes an obstacle to resolving the conflict. The third person usually is drawn into a coalition
with one of the parties in conflict and against the other. This coalition results in an imbalance within the
original dyad. The issues involved in the conflict are detoured through the third person rather than dealt with
directly. For example, when parent A has a fight with parent B, parent B may attack the adolescent in
retaliation for parent A's behavior (or attempt to enlist the youth's support for his or her side of the
argument) rather than expressing his or her anger directly to parent A. Such triangulated adolescents are
often blamed for the family's problems, and they may become identified patients and develop symptoms
such as drug abuse.
Because triangulation prevents the involved parties from resolving their conflicts, the goal of counseling is
to break up the triangle. Detriangulation permits the parents in conflict to discuss issues and feelings directly
and more effectively. Detriangulation also frees the third party, the adolescent, from being used as the
escape valve for the parents' problems.
One of the ways in which a BSFT counselor achieves detriangulation is by keeping the third party (i.e., the
adolescent) from participating in the discussions between the dyad. Another way to set boundaries to
detriangulate is to ask the third party not to attend a therapy session so that the two conflicting parties can
work on their issues directly. For example, when working with a family in which the son begins to act
disrespectfully whenever his parents begin to argue, the counselor might instruct the parents to ignore the
son and continue their discussion. If the son's misbehavior becomes unmanageable, the counselor may ask
the son to leave the room so that the parents can argue without the son's interference. Eventually, the
counselor will ask the parents to collaborate in controlling the son.
Attempts by the Family to Triangulate the Counselor
Triangulation does not necessarily have to involve only family members. Sometimes a counselor can
become part of a triangle as well. One of the most common strategies used by family members is to attempt
to get the counselor to ally himself or herself with one family member against another. For example, one
family member might say to the counselor, "Isn't it true that I am right and he is wrong?" "You know best,
you tell him." "We were having this argument last night, and I told her that you had said that...."
Triangulation is always a form of conflict avoidance. Regardless of whether it is the counselor or a family
member who is being triangulated, triangulation prevents two family members in conflict from reaching a
resolution. The only way two family members can resolve their conflicts is on a one-to-one basis.
An important reason why the counselor does not want to be triangulated is that the person in the middle of a
triangle is either rendered powerless or symptomatic. In the case of the counselor, the "symptom" he or she
would develop would be ineffectiveness as a therapist, that is an inability to do his or her job well because
his or her freedom of movement (e.g., changing alliances, choosing whom to address, etc.) has been
restricted. A triangulated counselor is defeated. If the counselor is unable to get out of the triangle, he or she
has no hope of being effective, regardless of what else he or she does or says.
When a family member attempts to triangulate the counselor, the counselor has to bring the conflict back to
the people who are involved in it. For example, the counselor might say, "Ultimately, it doesn't matter what
I think. What matters is what the two of you agree to, together. I am here to help you talk, negotiate, hear
each other clearly, and come to an agreement." In this way, the counselor places the focus of the interaction
back on the family. The counselor also might respond, "I understand how difficult this is for you, but this is
your son, and you have to come to terms with each other, not with me."
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6. Opening Up Closed Systems
Families in which conflicts are not openly expressed need help in discussing the conflict so that it can be a
target for change. Sometimes a counselor can work with a family member who has an unexpressed or
implicit conflict and help that person discuss the problem so that it can be resolved. This brings conflicts out
into the open and facilitates their resolution by intensifying and focusing on covert emotional issues. In
families of drug-abusing adolescents, a typical example of unexpressed or suppressed conflict involves
disengaged fathers who tend to deny or avoid any discussion of the youth's problems. Asking a surly or
sulking adolescent to express what is on his or her mind whenever the father is addressed may help the
father break through his denial.
7. Tasks
Central Role
The use of "tasks" or assignments is central to all work with families. The counselor uses tasks both inside
and outside the counseling sessions as the basic tool for orchestrating change. Because the emphasis in
BSFT is in promoting new skills among family members, at both the level of individual behaviors and in
family interactional relations, tasks serve as the vehicle through which counselors choreograph opportunities
for the family to behave differently.
In the example in which mother and son were initially allied and the father was left outside of this alliance,
father and son were first assigned the task of doing something together that would interest them both. Later
on, the mother and father were assigned the collaborative task of working together to define rules regarding
the types of behaviors they would permit in their son and the consequences that they would assign to their
son's behavior and misbehavior.
General Rule
It is a general rule that the BSFT counselor must first assign a task for the family to perform in the therapy
session so that the counselor has an opportunity to observe and help the family successfully carry out the
task. Only after a task has been accomplished successfully in the therapy session can a similar followup task
be assigned to the family to be completed outside of therapy.
Moreover, the counselor's aim is to provide the family with a successful experience. Thus, the counselor
should try to assign tasks that are sufficiently doable at each step of the counseling process. The counselor
should start with easy tasks and work up to more difficult ones, slowly building a foundation of successes
with the family before attempting truly difficult restructuring moves.
Hope for the Best; Be Prepared for the Worst
Counselors should never expect the family to accomplish the assigned tasks flawlessly. In fact, if family
members were skillful enough to accomplish all assigned tasks successfully, they would not need to be in
counseling. When tasks are assigned, counselors should always hope for the best but be prepared for the
worst. After all, a task represents a new way of behaving for the family and one that may be difficult given
that they have had years of practice engaging in the old ways of behaving.
As the family attempts to carry out a task, the counselor should help the family overcome obstacles it may
encounter. However, in spite of the counselor's best efforts, the task is not always accomplished. The
counselor's job is to observe and/or uncover what happened and identify the obstacles that prevented the
family from achieving the task. When a task fails, the counselor starts over and works to overcome the
newly identified obstacles. Unsuccessful attempts to complete tasks are a great source of new and important
information regarding the interactions that prevent a family from functioning optimally.
The first task that family counselors give to all of their cases is to bring everyone into the counseling
session. Every counselor who works with problem youths and their families knows very well that most of
the families who need counseling never reach the first counseling session. Therefore, these families can be
described as having failed the first task given them, to come in for counseling. This task, called engagement,
is so important that we have devoted the next chapter to it.
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Chapter 5 - Engaging the Family Into Treatment
Previous chapters have described the basic concepts of BSFT, how to assess and diagnose maladaptive
interactions and their relationship to symptoms, and the intervention strategies characteristic of this
approach. These concepts also are the building blocks for the techniques that are used to engage resistant
families into counseling.
This chapter defines, in systems terms, the nature of the problem of resistance to treatment and redefines the
nature of BSFT joining, diagnosing, and restructuring interventions in ways that take into account those
patterns of interaction that prevent families from entering treatment.
The Problem
Regardless of their professional orientation and where or how they practice, all counselors have had the
disappointing and frustrating experience of encountering "resistance to counseling" in the form of missed or
cancelled first appointments. For BSFT counselors, this becomes an even more common and complex issue
because more than one individual needs to be engaged to come to treatment.
Unfortunately, some counselors handle engagement problems by accepting the resistance of some family
members. In effect, the counselor agrees with the family's assessment that only one member is sick and
needs treatment. Consequently, the initially well-intentioned counselor agrees to see only one or two family
members for treatment. This usually results in the adolescent and an overburdened mother following
through with counseling visits. Therefore, the counselor has been co-opted into the family's dysfunctional
process.
Not only has the counselor "bought" the family's definition of the problem, but he or she also has accepted
the family's ideas about who is the identified patient. When the counselor agrees to see only one or two
family members, instead of challenging the maladaptive family interaction patterns that kept the other
members away, he or she is reinforcing those family patterns. In the example in which a mother and son are
allied against the father, if the counselor accepts the mother and son into counseling, he or she is reinforcing
the father figure's disengagement.
At a more complex level, there are serious clinical implications for the counselor who accepts the family's
version of the problem. In doing this, the counselor surrenders his or her position as the expert and leader. If
the counselor agrees with the family's assessment of "who's got the problem," the family will perceive his or
her expertise and ability to understand the issues as no greater than its own. The counselor's credibility as a
helper and the family's perception of his or her competence will be at stake. Some family members may
perceive the counselor as unable to challenge the status quo in the family because, in fact, he or she has
failed to achieve the first and defining reframe of the problem.
When the counselor agrees to see only part of the family, he or she may have surrendered his or her
authority too early and may be unable to direct change and to move freely from one family member to
another. Thus, by beginning counseling with only part of the family, excluded family members may see the
counselor as being in a coalition with the family members who originally participated in therapy. Therefore,
the family members who didn't attend the initial sessions may never come to trust the counselor. This means
that the counselor will not be able to observe the system as a whole as it usually operates at home because
the family members who were not involved in therapy from the beginning will not trust the counselor
sufficiently to behave as they would at home. The counselor, then, will be working with the family knowing
only one aspect of how the family typically interacts.
Some counselors respond to the resistance of some family members to attend counseling by agreeing to see
only those who wish to come. Other family counselors have resolved the dilemma of what to do when only
some family members want to go to counseling by taking a more alienated stance saying: "There are too
many motivated families waiting for help; the resistant families will call back when they finally feel the
need; there is no need to get involved in a power struggle." The reality is that these resistant families will
most likely never come to counseling by themselves. Ironically, the families who most need counseling are
those families whose patterns and habits interfere with their ability to get help for themselves.
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Dealing With Resistance to Engagement
When some family members do not want to participate in treatment, has called the counselor asking for
help, that parent is not powerful enough to bring the adolescent into counseling. If the counselor wants the
family to be in counseling, he or she will have to recognize that the youth (or a noncooperative parent
figure) is the most powerful person in the family. Once the reason the family is not in treatment is
understood, the counselor can draw upon the concept of tracking (as defined in Chapter 4) to find a way to
reach this powerful person directly and negotiate a treatment contract to which the person will agree.
Counselors should not become discouraged at this stage. Their mission now is to identify the obstacles the
family faces and help it surmount them. It is essential to keep in mind that a family seeks counseling
because it is unable to overcome an obstacle without help. Failed tasks, such as not getting the family to
come in for treatment, tend to be a great source of new and important information regarding the reasons why
a family cannot do what is best for them. The most important question in counseling is, "What has happened
that will not allow some families to do what may be best for them?"
In trying to engage the family in treatment, the counselor should apply the concept of repetitive patterns of
maladaptive interaction, which give rise to and maintain symptoms, to the problem of resistance to entering
treatment. The very same principles that apply to understanding family functioning and treatment also apply
to understanding and treating the family's resistance to entering counseling. When the family wishes to get
rid of the youth's drug abuse symptom by seeking professional help, the same interactive patterns that
prevented it from getting rid of the adolescent's symptom also prevent the family from getting help. The
term "resistance" is used to refer to the maladaptive interactive patterns that keep families from entering
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treatment. From a family-systems perspective, resistance is nothing more than the family's display of its
inability to adapt effectively to the situation at hand and to collaborate with one another to seek help. Thus,
the key to eliminating the resistance to counseling lies within the family's patterns of interaction; overcome
the resistance in the interactional patterns and the family will come to counseling.
In working to overcome resistant patterns of family interaction, tasks play a particularly vital role because
they are the only BSFT intervention used outside the therapy session. For this reason, tasks are particularly
well-suited for use during the engagement period, when crucial aspects of the family's work in overcoming
resistance to counseling need to take place outside the office--obviously--because the family has not yet
come in.
The central task around which engagement is organized is getting the family to come to therapy together.
Thus, in engagement, the counselor assigns tasks that involve doing whatever is needed to get the family
into treatment. For example, a father calls a BSFT counselor and asks for help with his drug-abusing son.
The counselor responds by suggesting that the father bring his entire family to a session so that he or she
can involve the whole family in fixing the problem. The father responds that his son would never come to
treatment and that he doesn't know what to do. The first task that the counselor might assign the father is to
talk with his wife and involve her in the effort to bring their son into treatment.
The Task of Coming to Treatment
The simple case. The counselor gives the task of bringing the whole family into counseling to the family
member who calls for help. The counselor explains why this task is a good idea and promises to support the
family as it works at this task. Occasionally, this is all that is needed. Often people do not request family
counseling simply because family counseling is not well known, and thus it does not occur to them to take
such action.
Fear, an obstacle that might easily be overcome. Sometimes, family members are afraid of what will happen
in family therapy. Some of these fears may be real; others may be simply imagined. In some instances,
families just need some reassuring advice to overcome their fears. Such fears might include, "They are
going to gang up on me," or "Everyone will know what a failure I am." Once these family members have
been helped to overcome their fears, they will be ready to enter counseling.
Tasks to change how family members act with each other. Very often, however, simple clarification and
reassurance is not sufficient to mobilize a family. It is at this point that tasks that apply joining, diagnostic,
and restructuring strategies are useful in engaging the family. The counselor needs to prescribe tasks for the
family members who are willing to come to therapy. These need to be tasks that attempt to change the ways
in which family members interact when discussing coming to therapy. In the process of carrying out these
tasks, the family's resistance will come to light. When that happens, the counselor will have the diagnostic
information needed to get around the family's patterns of interaction that are maintaining the symptom of
resistance. Once these patterns are changed, the family will come to therapy.
It should not be a surprise that families fail to accomplish the task of getting all of their members to
counseling. In fact, the therapist's job is to help the families accomplish tasks that they are not able to
accomplish on their own. As discussed earlier, when assigning any task, the counselor must expect that the
task may not be performed as requested. This is certainly the case when the family is asked to perform the
task of coming together to counseling.
The application of joining, diagnosing, and restructuring techniques to the engagement of resistant families
is discussed separately below. However, these techniques are used simultaneously during engagement, as
they are during counseling.
Joining
Joining the resistant family begins with the first contact with the family member who calls for help and
continues throughout the entire relationship with the family.
With resistant families, the joining techniques described earlier have to be adapted to match the goal of this
phase of therapy. For example, in tracking the resistant family members to engage them, it is necessary to
track through the caller or initial help seeker and any other family members who may be involved in the
process of bringing the family to counseling. The counselor tracks by "following" from the first family
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member to the next available family member to the next one and so on. This following, or tracking, is done
without challenging the family patterns of interaction. Rather, tracking is accomplished by gaining the
permission of one family member to reach the others.
Establishing a Therapeutic Alliance
An effective way for the counselor to establish a therapeutic alliance they want to solve their problems and
that the counselor wants the same thing. It must be recognized, however, that each family member may
view the problem differently. For example, the mother may want to get her son to quit using drugs, while
the son may want peace at home.
A therapeutic alliance is built around individual goals that family members can reach in therapy. Ideally, the
counselor and the family members agree on a goal, and therapy is offered in the framework of achieving
that goal. However, in families in which members are in conflict over their goals, it is necessary to find
something for each of them to achieve in therapy. For example, the counselor can say to the mother that
therapy can help her son stop using drugs, to the son that therapy can help him get his mother off his back
and stop her nagging, and to the father that therapy can help stop his being called in constantly to play the
"bad guy." In each case, the counselor can offer counseling as a means for each family member to achieve
his or her own personal goal.
In engaging resistant families, the counselor initially works with and through only one or a few family
members. Because the entire family is not initially available, the counselor will need to form a bond with
the person who called for help and any other family members that make themselves available. However, the
focus of this early engagement phase is strictly to work with these people to bring about the changes
necessary to engage the entire family in counseling. The focus is not to talk about the problem but rather to
talk about getting everyone to help solve the problem by coming to therapy. By using the contact person as
a vehicle (via tracking) for joining with other members of the family, the counselor can eventually establish
a therapeutic alliance with each family member and thereby elicit the cooperation of the entire family in the
engagement effort.
Diagnosing the Interactions That Keep the Family From Coming Into Treatment
In engagement, the purpose of diagnosis is to identify those particular patterns of interaction that permit the
resistant behavior to continue. However, because it isn't possible to observe the entire family, the BSFT
counselor works with limited information to diagnose those patterns of interaction that are supporting the
resistance.
To identify the maladaptive patterns responsible for the resistance, diagnosis begins prior to therapy, when a
family member first calls the counselor. Because it is not possible to encourage and observe enactments of
family members interacting before they enter counseling, engagement diagnosis has been modified so that it
can be used during engagement to collect the diagnostic information in other ways.
First, the counselor asks the contact person interpersonal systems questions that allow him or her to infer
what the family's interactional patterns may be. For example, the counselor may ask, "How do you ask your
husband to come to treatment?" "What happens when you ask your husband to come to treatment?" "When
he gets angry at you for asking him to come to treatment, what do you do next?" Through these questions,
the counselor tries to identify the interplay between these spouses that contributes to the resistance. For
example, is it possible that the wife is asking the husband to come to treatment in an accusatory way, which
causes him to get angry? An example might be, "It is your fault that your son is in trouble because you are
sick. You have to go to treatment."
As was indicated earlier, counselors do not like to rely on what family members tell them because each
family member is very invested in his or her own viewpoints and probably cannot provide a systemic or
objective account of family functioning. However, when counselors have access to only one person, they
work with the person they have, strictly for the purpose of engaging that person in treatment.
Second, counselors explore the family system for resistances to the task of coming to therapy. This is done
by assigning exploratory tasks to uncover resistances that cause the family to fail at the task of coming to
therapy. For example, in the case above, the counselor might suggest to the wife that she ask her husband to
come for her sake and not because there is anything wrong with him. At that point, the wife may say to the
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counselor, "I can't really ask him for my sake because I know he's too busy to come to the family meetings."
This statement suggests that the wife is not completely committed to getting the husband to come to
treatment. On the one hand, she claims to want him to come to treatment, but on the other, she gives excuses
for why he cannot. The purpose of exploring the resistance, beginning with the first phone call, is to identify
as early as possible the obstacles that may prevent the family from coming to therapy, with the aim of
intervening in a way that gets around these obstacles.
Complementarity: Understanding How the Family "Pieces" Fit Together to Create Resistance
What makes this type of early diagnostic work possible is an understanding of the Principle of
Complementarity, which was described in Chapter 2. As noted earlier, for a family to work as a unit (even
maladaptively), the behaviors of each family member must "fit with" the behaviors of every other family
member. Thus, for each action within the family, there is a complementary action or reaction. For example,
in the case of resistance, the husband doesn't want to come to treatment (the action), and the wife excuses
him for not coming to treatment (the complementary action). Similarly, a caller tells the counselor that
whenever she says anything to her husband about counseling (the action), he becomes angry (the
complementary reaction). The counselor needs to know exactly what the wife's contribution is to this
circular transaction, that is, what her part is in maintaining this pattern of resistance.
Restructuring the Resistance
In the process of engaging resistant families, the counselor initially sees only one or a few of the family
members. It is still possible, through these individuals, to bring about short-term changes in interactional
patterns that will allow the family to come for therapy. A variety of change-producing interventions have
already been described in Chapter 4: reframing, reversals, detriangulation, opening up closed systems,
shifting alliances, and task setting. The counselor can use all of these techniques to overcome the family's
resistance to counseling. In the process of engaging resistant families, task setting is particularly useful in
restructuring.
The next section discusses the types of resistant families that have been identified, the process of getting the
family into counseling, and the central role that tasks may play in achieving this goal. Much of counseling
work with resistant families has been done with families in which the parents knew or believed the
adolescent was using drugs and engaging in associated problem behaviors such as truancy, delinquency,
fighting, and breaking curfew. These types of families are typically difficult to engage in therapy. However,
the examples are not intended to represent all possible types of configurations of family patterns of
interaction that work to resist counseling. Counselors working with other types of problems and families are
encouraged to review their caseload of difficult-to-engage families and to carefully diagnose the systemic
resistances to therapy. Some counselors may find that the resistant families they work with are similar to
those described here, and some may find different patterns of resistance. In any case, counselors will be
better equipped to work with these families if they have some understanding of the more common types of
resistances in families of adolescent drug abusers.
Types of Resistant Families
There are four general types of family patterns of interaction that emerge repeatedly in work with families
of drug-abusing adolescents who resist engagement to therapy. These four patterns are discussed below in
terms of how the resistant patterns of interaction are manifested, how they come to the attention of the
counselor, and how the resistance can be restructured to get the family into therapy.
Powerful Identified Patient
The most frequently observed type of family resistance to entering treatment is characterized by an
identified patient who has a powerful position in the family and whose parents are unable to influence him
or her. This is a problem, particularly in cases that are not courtreferred and in which the adolescent
identified patient is not required to engage in counseling. Very often, the parent of a powerful identified
patient will admit that he or she is weak or ineffective and will say that his or her son or daughter flatly
refuses to come to counseling. Counselors can assume that the identified patient resists counseling for two
reasons: It threatens his or her position of power, and counseling is on the parent's agenda and compliance
would strengthen the parent's power.
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As a first step in joining and tracking the rules of the family, the counselor shows respect for and allies with
the adolescent. The counselor contacts the drug-abusing adolescent by phone or in person (perhaps on his or
her own turf, such as after school at the park). The counselor listens to the powerful adolescent's complaints
about his or her parents and then offers to help the youth change the situation at home so that the parents
will stop harassing him or her. This does not threaten the adolescent's power within the family and, thus, is
likely to be accepted. The counselor offers respect and concern for the youth and brings an agenda of
change that the adolescent will share by virtue of the alliance.
To bring these families who resist entering treatment into treatment, the counselor does not directly
challenge the youth's power in the family. Instead, the counselor accepts and tracks the adolescent's power.
The counselor allies himself or herself with the adolescent so that he or she may later be in a position to
influence the adolescent to change his or her behavior. Initially, in forming an alliance with the powerful
adolescent, the counselor reframes the need for counseling in a manner that strengthens the powerful
adolescent in a positive way. This is an example of tracking--using the power of the adolescent to bring him
or her into therapy. The kind of reframing that is most useful with powerful adolescents is one that transfers
the symptom from the powerful adolescent/identified patient to the family. For example, the counselor may
say, "I want you to come into counseling to help me change some of the things that are going on in your
family." Later, once the adolescent is in counseling, the counselor will challenge the adolescent's position of
power.
It should be noted that in cases in which powerful adolescents have less powerful parents, forming the initial
alliance with the parents is likely to be ineffective because the parents are not strong enough to bring their
adolescent into counseling. Their failed attempts to bring the adolescent into counseling would render the
parents even weaker, and the family would fail to enter counseling. Furthermore, the youth is likely to
perceive the counselor as being the parents' ally, which would immediately make the adolescent distrust the
weak counselor.
Contact Person Protecting Structure
The second most common type of resistance to entering treatment is characterized by a parent who protects
the family's maladaptive patterns of interaction. In these families, the person (usually the mother) who
contacts the counselor to request help is also the person who is-- without realizing it--maintaining the
resistance in the family. The way in which the identified patient is maintained in the family is also the way
in which counseling is resisted. The mother, for example, might give conflicting messages to the counselor,
such as, "I want to take my family to counseling, but my son couldn't come to the session because he forgot
and fell asleep, and my husband has so much work he doesn't have the time."
The mother is expressing a desire for the counselor's help while protecting and allying herself with the
family's resistance to being involved in solving the problem. The mother protects this resistance by agreeing
that the excuses for noninvolvement are valid. In other words, she is supporting the arguments the other
family members are using to maintain the status quo. It is worthwhile to note that ordinarily this same
conflicting message that occurs in the family maintains the symptomatic structure. In other words, someone
complains about the problem behavior, yet supports the maintenance of the behaviors that nurture the
problem. This pattern is typical of families in which the caller (e.g., the mother) and the identified patient
are enmeshed.
To bring these families into treatment, the counselor must first form an alliance with the mother by
acknowledging her frustration in wanting to get help and not getting any cooperation from the other family
members to get it. Through this alliance, the counselor asks the mother's permission to contact the other
family members "even though they are busy and the counselor recognizes how difficult it is for them to
become involved." With the mother's permission, the counselor calls the other family members and
separates them from the mother in regard to the issue of coming to counseling. The counselor develops his
or her own relationship with other family members in discussing the importance of coming to counseling. In
doing so, he or she circumvents the mother's protective behaviors. Once the family is in counseling, the
mother's overprotection of the adolescent's misbehavior and of the father's uninvolvement (and the
adolescent's and father's eagerness that she continue to protect them) will be addressed because it also may
be related to the adolescent's problem behaviors.
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Disengaged Parent
These family structures in which one parent protects the family's maladaptive patterns of behavior are
characterized by little or no cohesiveness and lack of an alliance between the parents or parent figures as a
subsystem. One of the parents, usually the father, refuses to come into therapy. This is typically a father
who has remained disengaged from the problems at home. The father's disengagement not only protects him
from having to address his adolescent's problems but also protects him from having to deal with the marital
relationship, which is most likely the more troublesome of the two relationships he is avoiding. Typically,
the mother is over-involved (enmeshed) with the identified patient and either lacks the skills to manage the
youth or is supporting the identified patient in a covert fashion.
For example, if the father tries to control the adolescent's behavior, the mother complains that he is too
tough or makes her afraid that he may become violent.2 The father does not challenge this portrayal of
himself. He is then rendered useless and again distances himself, re-establishing the disengagement between
husband and son and between husband and wife. In this family, the dimension of resonance is of foremost
importance in planning how to change the family and bring it into therapy. The counselor must use tasks to
bring the mother closer to the father and distance her from the son. That is, the boundary between the
parents needs to be loosened to bring them closer together, and the boundary between mother and son needs
to be strengthened to create distance between them.
To engage these families into treatment, the counselor must form an alliance with the person who called for
help (usually the mother). The counselor then must begin to direct the mother to change her patterns of
interaction with the father to improve their cooperation, at least temporarily, in bringing the family into
treatment. The counselor should give the mother tasks to do with her husband that pertain only to getting the
family into treatment and taking care of their son's problems. The counselor should assign tasks in a way
that is least likely to spark the broader marital conflict. To set up the task, the counselor may ask the mother
what she believes is the real reason her husband does not want to come to counseling. Once this reason is
ascertained, the counselor coaches the mother to present the issue of coming to treatment in a way that the
husband can accept. For example, if he doesn't want to come because he has given up on his son, she may
be coached to suggest to him that coming to treatment will help her cope with the situation.
Although the pattern of resistance is similar to that of the contact person protecting the structure, in this
instance, the resistance emerges differently. In this case, the mother does not excuse the father's distance. To
the contrary, she complains about her spouse's disinterest; this mother is usually eager to do something to
involve her husband; she just needs some direction to be able to do it.
Families With Secrets
ometimes counseling is threatening to one or more individuals in the family. Sometimes the person who
resists coming to counseling is either afraid of being made a scapegoat or afraid that dangerous secrets (e.g.,
infidelity) will be revealed. These individuals' beliefs or frames about counseling are usually an extension of
the frame within which the family is functioning. That is, it is a family of secrets. The counselor must
reframe the idea or goal of counseling in a way that eliminates its potential negative consequences and
replaces them with positive aims. One example of how to do this is to meet with the person who rejects
counseling the most and assure him or her that counseling does not have to go where he or she does not
want it to go. The counselor needs to make it clear that he or she will make every effort to focus on the
adolescent's problems instead of the issues that might concern the unwilling family member. The counselor
also should assure this individual that in the counseling session, "We will deal only with those issues that
you want to deal with. You'll be the boss. I am here only to help you to the extent that you say."
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Chapter 6 - Clinical Research Supporting Brief Stategic Family Therapy
This chapter describes past research on the effectiveness of BSFT with drug-abusing adolescents with
behavioral problems. BSFT has been found to be effective in reducing adolescents' conduct problems, drug
use, and association with antisocial peers and in improving family functioning. In addition, BSFT
engagement has been found to increase engagement and retention in therapy. Additional studies testing an
ecological version of BSFT with this population are currently underway.
As presented in this manual, BSFT's primary emphasis is on identifying and modifying maladaptive patterns
of family interaction that are linked to the adolescent's symptoms. The ecological version of BSFT, BSFTecological
(Robbins et al. in press) applies this principle of identifying and modifying maladaptive patterns
of interaction to the multiple social contexts in which the adolescent is embedded (cf. Bronfenbrenner
1979). The principal social contexts that are targeted in BSFT-ecological are family, family-peer relations,
family-school relations, family-juvenile justice relations, and parent support systems. Joining, diagnosing,
and restructuring, as developed in BSFT to use within the family system, are applied to these other social
contexts or systems that influence the adolescent's behaviors. For instance, the BSFT counselor assesses the
maladaptive, repetitive patterns of interaction that occur in each of these systems or domains. As an
example, the BSFT counselor would diagnose the family-school system in the same way that he or she
would diagnose the family system. In diagnosing structure, the counselor would ask, "Do parents provide
effective leadership in their relationship with their child's teachers?" In diagnosing resonance, the counselor
would ask, "Are parents and teachers disengaged?" In diagnosing conflict resolution, the counselor's
questions would be, "What is the conflict resolution style in the parentteacher relationship? Might parents
and teachers avoid conflict with each other (by remaining disengaged) or diffuse conflicts by blaming each
other?" In BSFT-ecological, joining the teacher in the parentteacher relationship employs the same joining
techniques developed for BSFT. Similarly, in BSFT-ecological, BSFT restructuring techniques are used to
modify the nature of the relationship between a parent and his or her child's teacher.
Outpatient Brief Strategic Family Therapy Versus Outpatient Group Counseling
A recent study (Santisteban et al. in press) examined the efficacy of BSFT in reducing an adolescent's
behavioral problems, association with antisocial peers, and marijuana use, and in improving family
functioning. In this study, outpatient BSFT was compared to an outpatient group counseling control
treatment. Participants were 79 Hispanic families with a 12- to 18-year-old adolescent who was referred to
counseling for conduct and antisocial problems by either a school counselor or a parent. Families were
randomly assigned to either BSFT or group counseling. Analyses of treatment integrity revealed that
interventions in both therapies adhered to treatment guidelines and that the two therapies were clearly
distinguishable.
Conduct disorder and association with antisocial peers
Conduct disorder and association with antisocial peers were assessed using the Revised Behavior Problem
Checklist (RBPC) (Quay and Peterson 1987), which is a measure of adolescent behavior problems reported
by parents. Conduct disorder was measured using 22 items, and association with antisocial peers was
measured using 17 items. Each item asks the parent(s) to rate whether a specific aspect of the adolescent's
behavior (e.g., fighting, spending time with "bad" friends) is no problem (0), a mild problem (1), or a severe
problem (2). Ratings for all items on each scale are then added together to derive a total score.
The effects of BSFT on conduct disorder, association with antisocial peers, and marijuana use were
evaluated in two ways. First, analyses of variance were conducted to examine whether BSFT reduced
conduct disorder, association with antisocial peers, and marijuana use to a significantly greater extent than
did group counseling. Second, exploratory analyses were conducted on clinically significant changes in
conduct problems and association with antisocial peers. These exploratory analyses used the twofold
clinical significance criteria recommended by Jacobson and Truax (1991). To be able to classify a change in
symptoms for a given participant as clinically significant, two conditions have to occur. First, the magnitude
of the change must be large enough to be reliable--that is, to rule out random fluctuation as a plausible
explanation. Second, the participant must "recover" from clinical to nonclinical levels, i.e., cross the
diagnostic threshold.
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Conduct Disorder.
Analyses of variance indicated that conduct disorder scores for adolescents in BSFT compared to those for
adolescents in group counseling were significantly reduced between pre- and posttreatment. In the clinical
significance analyses, a substantially larger proportion of adolescents in BSFT than in group counseling
demonstrated clinically significant improvement. At intake, 70 percent of adolescents in BSFT had conduct
disorder scores that were above clinical cutoffs. That is, they scored above the empirically established
threshold for clinical diagnoses of conduct disorder. At the end of treatment, 46 percent of these adolescents
showed reliable improvement, and 5 percent showed reliable deterioration. Among the 46 percent who
showed reliable improvement, 59 percent recovered to nonclinical levels of conduct disorder. In contrast, at
intake, 64 percent of adolescents in group counseling had conduct disorder scores above the clinical cutoff.
Of these, none showed reliable improvement, and 11 percent showed reliable deterioration. Therefore, while
adolescents in BSFT who entered treatment at clinical levels of conduct disorder had a 66 percent likelihood
of improving, none of the adolescents in group counseling reliably improved.
Association With Antisocial Peers.
Analyses of variance indicated that, for adolescents in BSFT, scores for association with antisocial peers
were significantly reduced between pre- and post-treatment, compared to those for adolescents in group
counseling. In the clinical significance analyses, 79 percent of adolescents in BSFT were above clinical
cutoffs for association with antisocial peers at intake. Among adolescents in BSFT meeting clinical criteria
for association with antisocial peers, 36 percent showed reliable improvement, and 2 percent showed
reliable deterioration. Of the 36 percent of adolescents in BSFT with reliable improvement, 50 percent were
classified as recovered. Among adolescents in group counseling, 64 percent were above clinical cutoffs for
association with antisocial peers at intake. Among adolescents in group counseling meeting these clinical
criteria at intake, 11 percent reliably improved, and none reliably deteriorated. Of the 11 percent of
adolescents in group counseling evidencing reliable improvement in association with antisocial peers, 50
percent recovered to nonclinical levels. Hence, adolescents in BSFT who entered treatment at clinical levels
of association with antisocial peers were 2.5 times more likely to reliable improve than were adolescents in
group treatment. Marijuana Use. Analyses of variance revealed that BSFT was associated with significantly
greater reductions in self-reported marijuana use than was group counseling. To investigate whether
clinically meaningful 3 changes in marijuana use occurred, four use categories from the substance use
literature (e.g., Brooks et al.1998) were employed.
These categories are based on the number of days an individual uses marijuana in the 30 days before the
intake and termination assessments:
abstainer - 0 days
weekly user - 1 to 8 days
frequent user - 9 to 16 days
daily user - 17 or more days
In BSFT, 40 percent of participants reported using marijuana at intake and/or termination. Of these, 25
percent did not show change, 60 percent showed improvement in drug use, and 15 percent showed
deterioration. Of the individuals in BSFT who shifted into less severe categories, 75 percent were no longer
using marijuana at termination. In group counseling, 26 percent of participants reported using marijuana at
intake and/or termination. Of these, 33 percent showed no change, 17 percent showed improvement, and 50
percent deteriorated. The 17 percent of adolescents in group counseling cases that showed improvement
were no longer using marijuana at termination. Hence, adolescents in BSFT were 3.5 times more likely than
were adolescents in group counseling to show improvement in marijuana use.
Treatments also were compared in terms of their influence on family functioning. Family functioning was
measured using the Structural Family Systems Ratings (Szapocznik et al. 1991). This measure was
constructed to assess family functioning as defined in Chapter 3. Based on their scores when they entered
therapy, families were separated by a median split into those who had good and those who had poor family
functioning. Within each group (i.e., those with good and those with poor family functioning), a statistical
test that compares group means (analysis of variance) tested changes in family functioning from before to
after the intervention.
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Among families who were admitted with poor family functioning, the results showed that those assigned to
BSFT had a significant improvement in family functioning, while those families assigned to group
counseling did not improve significantly.
Among families who were admitted with good family functioning, the results showed that those assigned to
BSFT retained their good levels of family functioning, while families assigned to group counseling showed
significant deterioration. These findings suggest that not all families of drug-abusing youths begin
counseling with poor family functioning, but if the family is not given adequate help to cope with the
youth's problems, the family's functioning may deteriorate.
One Person Brief Strategic Family Therapy
With the advent of the adolescent drug epidemic of the 1970s, the vast majority of counselors who worked
with drug-using youths reported that, although they preferred to use family therapy, they were not able to
bring whole families into treatment (Coleman and Davis 1978). In response, a procedure was developed that
would achieve the goals of BSFT (to change maladaptive family interactions and symptomatic adolescent
behavior) without requiring the whole family to attend treatment sessions. The procedure is an adaptation of
BSFT called "One Person" BSFT (Szapocznik et al. 1985; Szapocznik and Kurtines 1989; Szapocznik et al.
1989a). One Person BSFT capitalizes on the systemic concept of complementarity, which suggests that
when one family member changes, the rest of the system responds by either restoring the family process to
its old ways or adapting to the new changes (Minuchin and Fishman 1981). The goal of One Person BSFT is
to change the drug-abusing adolescent's participation in maladaptive family interactions that include him or
her. Occasionally, these changes create a family crisis as the family attempts to return to its old ways. The
counselor uses the opportunity created by these crises to engage reluctant family members.
A clinical trial was conducted to compare the efficacy of One Person BSFT to Conjoint (full family) BSFT
(Szapocznik et al. 1983, 1986). Hispanic families with a drug-abusing 12- to 17-year-old adolescent were
randomly assigned to the One Person or Conjoint BSFT modalities. Both therapies were designed to use
exactly the same BSFT theory so that only one variable (one person vs. conjoint meetings) would differ
between the treatments. Analyses of treatment integrity revealed that interventions in both therapies adhered
to guidelines and that the two therapies were clearly distinguishable. The results showed that One Person
was as efficacious as Conjoint BSFT in significantly reducing adolescent drug use and behavior problems as
well as in improving family functioning at the end of therapy. These results were maintained at the 6-month
followup (Szapocznik et al. 1983, 1986).
One Person BSFT is not discussed in this manual because it is considered a very advanced clinical
technique. More information on One Person BSFT is available in Szapocznik and Kurtines (1989).
Brief Strategic Family Therapy Engagement
As discussed in Chapter 5, in response to the problem of engaging resistant families, a set of engagement
procedures based on BSFT principles was developed (Szapocznik and Kurtines 1989; Szapocznik et al.
1989b). These procedures are based on the premise that resistance to entering treatment can be understood
in family interactional terms.
One Person BSFT techniques are useful in this initial phase. That's because the person who contacts the
counselor to request help may become the one person through whom work is initially done to restructure the
maladaptive family interactions that are maintaining the symptom of resistance. The success of the
engagement process is measured by the family's and the symptomatic youth's attendance in family therapy.
In part, success in engagement permits the counselor to redefine the problem as a family problem in which
all family members have something to gain. Once the family is engaged in treatment, the focus of the
intervention is shifted from engagement to removing the adolescent's presenting symptoms.
The efficacy of BSFT engagement has been tested in three studies with Hispanic youths (Szapocznik et al.
1988; Santisteban et al. 1996; Coatsworth et al. 2001). The first study (Szapocznik et al. 1988) included
mostly Cuban families with adolescents who had behavior problems and who were suspected of or observed
using drugs by their parents or school counselors. Of those engaged, 93 percent actually reported drug use.
Families were randomly assigned to one of two therapies: BSFT engagement or engagement as usual (the
control therapy). The engagement-as-usual therapy consisted of the typical engagement methods used by
community treatment agencies, which were identified prior to the study using a community survey of
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outpatient agencies serving drug-abusing adolescents. All families who were successfully engaged received
BSFT. In the experimental therapy, families were engaged and retained using BSFT engagement
techniques. Successful engagement was defined as the conjoint family (minimally the identified patient and
his or her parents and siblings living in the same household) attending the first BSFT session, which was
usually to assess the drug-using adolescent and his or her family. Treatment integrity analyses revealed that
interventions in both engagement therapies adhered to prescribed guidelines using six levels of engagement
effort that were operationally defined and that the therapies were clearly distinguishable by level of
engagement effort applied.
The six levels of engagement effort
The six levels of engagement effort, as enumerated in Szapocznik et al. (1988, p. 554), are:
Level 0 - expressing polite concern, scheduling an intake appointment, establishing that cases met criteria
for inclusion in the study, and making clear who must attend the intake assessment;
Level 1 - attempting minimal joining, encouraging the caller to involve the family, asking about the depth
and breadth of adolescent problems, and asking about family members;
Level 2 - attempting more thorough joining; asking about family interactions; seeking information about
the problems, values, and interests of family members; supporting and establishing an alliance with the
caller; beginning to establish leadership; and asking whether all family members would be willing to attend
the intake appointment;
Level 3 - restructuring for engagement through the caller, advising the caller about negotiating and
reframing, and following up with family members (either over the phone or personally with the caller at the
therapist's office) to be sure that intake appointments would be kept;
Level 4 - conducting lower level ecological engagement interventions, joining family members or
conducting intrapersonal restructuring (with family members other than the original caller) over the phone
or in the therapist's office, and contacting significant others (by phone) to gather more information; and
Level 5 - conducting higher level ecological interventions, making out-of-office visits to family members
or significant others, and using significant others to help conduct restructuring.
Level 0-1 behaviors were permitted for both the BSFT engagement and engagement-as-usual conditions.
Level 2-5 behaviors were permitted only for the BSFT engagement condition. Efficacy was measured in
rates of both family treatment entry as well as retention to treatment completion.
Efficacy of methods of engagement
The efficacy of the two methods of engagement was measured by the percentage of families who entered
treatment and the percentage of families who completed the treatment. The results revealed that 42 percent
of the families in the engagement-as-usual therapy and 93 percent of the families in the BSFT engagement
therapy were successfully engaged. In addition, 25 percent of engaged cases in the engagement-as-usual
treatment and 77 percent of engaged cases in the BSFT engagement treatment successfully completed
treatment. These differences in engagement and retention between the two methods of engagement were
both statistically significant. Improvements in adolescent symptoms occurred but were not significantly
different between the two methods of engagement. Thus, the critical distinction between the treatments was
in their different rates of engagement and retention. Therefore, BSFT engagement had a positive impact on
more families than did engagement as usual.
In addition to replicating the previous engagement study, the second study (Santisteban et al. 1996) also
explored factors that might moderate the efficacy of the engagement interventions. In contrast to the
previous engagement study, Santisteban et al. (1996) more stringently defined the success of engagement as
a minimum of two office visits: the intake session and the first therapy session. The researchers randomly
assigned 193 Hispanic families to one experimental and two control treatments. The experimental therapy
was BSFT plus BSFT engagement. The first control therapy was BSFT plus engagement as usual, and the
second was group counseling plus engagement as usual. In both control treatments, engagement as usual
involved no specialized engagement strategies.
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Results showed that 81 percent of families were successfully engaged in the BSFT plus BSFT engagement
experimental treatment. In contrast, 60 percent of the families in the two control therapies were successfully
engaged. These differences in engagement were statistically significant. However, the efficacy of the
experimental therapy procedures was moderated by the cultural/ethnic identity of the Hispanic families in
the study. Among families assigned to BSFT engagement, 93 percent of the non-Cuban Hispanics
(composed primarily of Nicaraguan, Colombian, Puerto Rican, Peruvian, and Mexican families) and 64
percent of the Cuban Hispanics were engaged. These findings have led to further study of the mechanism by
which culture/ethnicity and other contextual factors may influence clinical processes related to engagement
(Santisteban et al. 1996; Santisteban et al. in press). The results of the Szapocznik et al. (1988) and
Santisteban et al. (1996) studies strongly support the efficacy of BSFT engagement. Further, the second
study with its focus on cultural/ethnic identity supports the widely held belief that therapeutic interactions
must be responsive to contextual changes in the treatment population (Sue et al. 1994; Szapocznik and
Kurtines 1993).
A third study (Coatsworth et al. 2001) compared BSFT to a community control intervention in terms of its
ability to engage and retain adolescents and their families in treatment. An important aspect of this study
was that an outside treatment agency administered the control intervention. Because of that, the control
intervention (e.g., usual engagement strategies) was less subject to the influence of the investigators.
Findings in this study, as in previous studies, showed that BSFT was significantly more successful, at 81
percent, in engaging adolescents and their families in treatment than was the community control treatment,
at 61 percent. Likewise, among those engaged in treatment, a higher percentage of adolescents and their
families in BSFT, at 71 percent, were retained in treatment compared to those in the community control
intervention, at 42 percent. In BSFT, 58 percent of adolescents and their families completed treatment
compared to 25 percent of those in the community control intervention. Families in BSFT were 2.3 times
more likely both to be engaged and retained in treatment than were families randomized to the community
control treatment.
An additional finding of the Coatsworth et al. (2001) study warrants special mention. In BSFT, families of
adolescents with more severe conduct problem symptoms were more likely to remain in treatment than were
families of adolescents whose conduct problem symptoms were less severe. The opposite pattern was
evident in the community control intervention, with families that were retained in treatment showing lower
intake levels of conduct problems than did families who dropped out. These findings are particularly
important because they suggest that adolescents who are most in need of services are more likely to stay in
BSFT than in traditional community treatments.
83

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Solution focused brief therapy
From Wikipedia, the free encyclopedia
Solution focused brief therapy (SFBT), often referred to as simply 'solution focused therapy' or 'brief
therapy', is a type of talking therapy that is based upon social constructionist philosophy. It focuses on what
clients want to achieve through therapy rather than on the problem(s) that made them to seek help.
The approach does not focus on the past, but instead, focuses on the present and future. The
therapist/counsellor uses respectful curiosity to invite the client to envision their preferred future and then
therapist and client start attending to any moves towards it whether these are small increments or large
changes. To support this, questions are asked about the client’s story, strengths and resources, and about
exceptions to the problem.
Solution focused therapists believe that change is constant. By helping people identify the things that they
wish to have changed in their life and also to attend to those things that are currently happening that they
wish to continue to have happen, SFBT therapists help their clients to construct a concrete vision of a
preferred future for themselves. The SFBT therapist then helps the client to identify times in their
current life that are closer to this future, and examines what is different on these occasions. By
bringing these small successes to their awareness, and helping them to repeat these successful things they do
when the problem is not there or less severe, the therapists helps the client move towards the preferred
future they have identified.
Solution focused work can be seen as a way of working that focuses exclusively or predominantly at two
things.
1) Supporting people to explore their preferred futures.
2) Exploring when, where, with whom and how pieces of that preferred future are already happening. While
this is often done using a social constructionist perspective the approach is practical and can be achieved
with no specific theoretical framework beyond the intention to keep as close as possible to these two things.
Basic Principles:
Contents
1 Basic Principles
2 Questions
3 Resources
4 History of Solution Focused Brief Therapy
5 Solution-Focused counselling
6 Solution-Focused consulting
7 References
Clients have resources and strengths to resolve complaints
It is therapist’s task to access these abilities and help clients put them to use.
Change is constant
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Therapists can do a great deal to influence client’s perceptions regarding the inevitability of change and
what is supposed to happen during the therapy session.
The therapist’s job is to identify and amplify change
He/She accomplishes this through choice of questions, topics focused on or ignored. “Focus on what seems
to be working however small, to label it as worthwhile, and to work toward amplifying it.” If [the change] is
in a crucial area, it can change the whole system.
It is usually unnecessary to know a great deal about the complaint in order to resolve it
What is significant is what the clients are doing that is working. Learn from clients’ identifying when the
problem is not troublesome. Clients can learn to function that way again to solve the problem.
It is not necessary to know the cause or function of a complaint to resolve it
Even the most creative hypotheses about the possible function of a symptom will not offer therapists a clue
about how people can change. It simply suggests how people’s lives have become static. Ask those who
want to know why they have a symptom: “Would it be enough if the problem were to disappear and you
never understood why had it?”
A small change is all that is necessary: A change in one part of the system can affect change in another part
of the system
“We have the sense that positive changes will at least continue and may expand and have beneficial effects
in other areas of the person’s life.
Clients define the goal
Do not assume that therapists are better equipped to decide how their clients should live their lives; ask
people to establish their own goals for treatment.
Rapid change or resolution of problems is possible
“We believe that, as a result of our interaction during the first session, our clients will gain a more
productive and optimistic view of their situations.” Therapists expect them to go home and do what is
necessary to make their lives more satisfying (p. 45). Average length of treatment is less than 10 sessions,
usually 4 to 5, occasionally only 1.
There is no one “right” way to view things; Different views may be just as valid and may fit the facts just as
well
Views that keep people stuck are simply not useful. Sometimes all that is necessary to initiate significant
change is a shift in the person’s perception of the situation.”
Focus on what is possible and changeable rather than what is impossible and intractable
Focus on aspects of a person’s situation that seem most changeable. This imparts a sense of hope and power
Questions
The miracle question
The miracle question is a method of questioning that a coach, therapist, or counsellor uses to aid the client to
envision how the future will be different when the problem is no longer present. Also, this may help to
establish goals.
A traditional version of the miracle question would go like this:
"Suppose our meeting is over, you go home, do whatever you planned to do for the rest of the day.
And then, some time in the evening, you get tired and go to sleep. And in the middle of the night,
when you are fast asleep, a miracle happens and all the problems that brought you here today are
solved just like that. But since the miracle happened overnight nobody is telling you that the miracle
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happened. When you wake up the next morning, how are you going to start discovering that the
miracle happened? ... What else are you going to notice? What else?"
Whilst relatively easy to state the miracle question requires considerable skill to ask well. The question must
be asked slowly with close attention to the person's non-verbal communication to ensure that the pace
matches the person's ability to follow the question. Initial responses frequently include a sense of "I don't
know." To ask the question well this should be met with respectful silence to give the person time to fully
absorb the question.
Once the miracle day has been thoroughly explored the worker can follow this with scales, on a scale where
0 = worst things have ever been and 10 = the miracle day where are you now? Where would it need to be
for you to know that you didn't need to see me any more? What will be the first things that will let you
know you are 1 point higher. In this way the miracle question is not so much a question as a series of
questions.
There are many different versions of the miracle question depending on the context and the client.
In a specific situation, the counsellor may ask,
"If you woke up tomorrow, and a miracle happened so that you no longer easily lost your temper,
what would you see differently?" What would the first signs be that the miracle occurred?"
The client (a child) may respond by saying,
"I would not get upset when somebody calls me names."
The counsellor wants the client to develop positive goals, or what they will do, rather than what they will
not do--to better ensure success. So, the counsellor may ask the client, "What will you be doing instead
when someone calls you names?"
Scaling Questions
Scaling questions are tools that are used to identify useful differences for the client and may help to
establish goals as well. The poles of a scale can be defined in a bespoke way each time the question is
asked, but typically range from "the worst the problem has ever been" (zero or one) to "the best things could
ever possibly be" (ten). The client is asked to rate their current position on the scale, and questions are then
used to help the client identify resources (e.g. "what's stopping you from slipping one point lower down the
scale?"), exceptions (e.g. "on a day when you are one point higher on the scale, what would tell you that it
was a 'one point higher' day?") and to describe a preferred future (e.g. "where on the scale would be good
enough? What would a day at that point on the scale look like?")
Exception Seeking Questions
Proponents of SFBT insist that there are always times when the problem is less severe or absent for the
client. The counsellor seeks to encourage the client to describe what different circumstances exist in that
case, or what the client did differently. The goal is for the client to repeat what has worked in the past, and
to help them gain confidence in making improvements for the future.
Coping questions
Coping questions are designed to elicit information about client resources that will have gone unnoticed by
them. Even the most hopeless story has within it examples of coping that can be drawn out: "I can see that
things have been really difficult for you, yet I am struck by the fact that, even so, you manage to get up each
morning and do everything necessary to get the kids off to school. How do you do that?" Genuine curiosity
and admiration can help to highlight strengths without appearing to contradict the clients view of reality.
The initial summary "I can see that things have been really difficult for you" is for them true and validates
their story. The second part "you manage to get up each morning etc.", is also a truism, but one that counters
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the problem focused narrative. Undeniably, they cope and coping questions start to gently and supportively
challenge the problem-focused narrative.
Problem-free talk
In solution-focused therapy, problem-free talk can be a useful technique for identifying resources to help the
person relax, or be more assertive, for example. Solution focused therapists will talk about seemingly
irrelevant life experiences such as leisure activities, meeting with friends, relaxing and managing conflict.
The therapist can also gather information on the client's values and beliefs and their strengths. From this
discussion the therapist can use these strengths and resources to move the therapy forward. For example; if a
client wants to be more assertive it may be that under certain life situations they are assertive. This strength
from one part of their life can then be transferred to the area with the current problem. Or if a client is
struggling with their child because the child gets aggressive and calls the parent names and the parent
continually retaliates and also gets angry, then perhaps they have an area of their life where they remain
calm even under pressure; or maybe they have trained a dog successfully that now behaves and can identify
that it was the way they spoke to the dog that made the difference and if they put boundaries in place using
the same firm tonality the child might listen.
Dan Jones, in his Becoming a Brief Therapist book writes:
'...it is in the problem free areas you find most of the resources to help the client. It also relaxes them and
helps build rapport, and it can give you ideas to use for treatment...Everybody has natural resources that can
be utilised. These might be events...or talk about friends or family...The idea behind accessing resources is
that it gives you something to work with that you can use to help the client to achieve their goal...Even
negative beliefs and opinions can be utilised as resources '
Resources
A key task in SFBT is to help clients identify and attend to their skills, abilities, and external resources (e.g.
social networks). This process not only helps to construct a narrative of the client as a competent individual,
but also aims to help the client identify new ways of bringing these resources to bear upon the problem.
Resources can be identified by the client and the worker will achieve this by empowering the client to
identify their own resources through use of scaling questions, problem-free talk, or during exceptionseeking.
Resources can be Internal:
the client's skills, strengths, qualities, beliefs that are useful to them and their capacities.
Or, External:
Supportive relationships such as, partners, family, friends, faith or religious groups and also support groups.
History of Solution Focused Brief Therapy
Solution Focused Brief Therapy is one of a family of approaches, known as systems therapies, that have
been developed over the past 50 years or so, first in the USA, and eventually evolving around the world,
including Europe. The title SFBT, and the specific steps involved in its practice, are attributed to husband
and wife Steve de Shazer and Insoo Kim Berg and their team at the Brief Family Therapy Center in
Milwaukee, USA. Core members of this team were Eve Lipchik, Wallace Gingerich, Elam Nunnally, Alex
Molnar, and Michele Weiner-Davis. Their work in the early 1980s built on that of a number of other
innovators, among them Milton Erickson, and the group at the Mental Research Institute at Palo Alto –
Gregory Bateson, Donald deAvila Jackson, Paul Watzlawick, John Weakland, Virginia Satir, Jay Haley,
Richard Fisch, Janet Beavin Bavelas and others.
The concept of brief therapy was independently discovered by several therapists in their own practices over
several decades (notably Milton Erickson), was described by authors such as Haley in the 1950s, and
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ecame popularized in the 1960s and 1970s. Richard Bandler, John Grinder and Stephen R Lankton have
also been credited, at least in part, with the inspiration for and popularization of brief therapy, particularly
through their work with Milton Erickson. While Jay Hayley and the team at the Mental Research Institute at
Palo Alto aimed to uncover the principles that underpinned Erickson's approach to brief therapy, John
Grinder and Richard Bandler provided practical guidelines for the application of some of the hypnotic
techniques of Erickson.
Solution Focused Brief Therapy has branched out in numerous spectrums - indeed, the approach is now
known in other fields as simply Solution Focus or Solutions Focus. Most notably, the field of Addiction
Counselling has begun to utilize SFBT as an effective means to treat problem drinking. The Center for
Solutions in Cando, ND has implemented SFBT as part of their program, wherein they utilize this therapy as
part of a partial hospitalization and residential treatment facility for both adolescents and adults.
Solution-Focused counselling
Solution-Focused counselling is a solution focused brief therapy model. Various similar, yet distinct,
models have been referred to as solution-focused counselling. For example, Jeffrey Guterman developed a
solution-focused approach to counselling in the 1990s. This model is an integration of solution-focused
principles and techniques, postmodern theories, and a strategic approach to eclecticism.
Solution-Focused consulting
Solution-Focused consulting is an approach to organizational change management that is built upon the
principles and practices of Solution-Focused therapy. While therapy is for individuals and families,
Solution-Focused consulting is being used as a change process for organizational groups of every size, from
small teams to large business units.
References
Jones, Dan Becoming a Brief Therapist: Special Edition The Complete Works, Lulu.com, 2008, page
451, ISBN 1-409-23031-7
See page 671 in Steenbarger (2002) "Single-session therapy: Theoretical underpinnings" In Elsevier
Encyclopedia of Psychotherapy
(Shazer 1982 p.22)
Shazer, SD. (1982) Patterns of brief family therapy: an ecosystemic approach. Guilford Press.
I.K.Berg and S.deShazer: Making numbers talk: Language in therapy. In S. Friedman (Ed.), "The new
language of change:
Constructive collaboration in psychotherapy." New York:Guilford, 1993.
I.K.Berg, "Family based services: A solution-focused approach." New York:Norton. 1994.
I.K.Berg; "Solution-Focused Therapy: An Interview with Insoo Kim Berg." Psychotherapy.net, 2003.
B.Cade and W.H. O’Hanlon: A Brief Guide to Brief Therapy. W.W. Norton & Co 1993.
D. Denborough; Family Therapy: Exploring the Field's Past, Present and Possible Futures. Adelaide,
South Australia: Dulwich Centre Publications, 2001.
Brief Therapy Strategies – George Carpetto
http://www.pearsonhighered.com/samplechapter/0205490786.pdf
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Brief (psycho-) therapy
From Wikipedia, the free encyclopedia And “Brief Therapy Strategies” by George Carpetto
Brief psychotherapy or Brief therapy is an umbrella term for a variety of approaches to psychotherapy.
It differs from other schools of therapy in that it emphasises
(1) a focus on a specific problem and
(2) direct intervention.
In brief therapy, the therapist takes responsibility for working more pro-actively with the client in order to
treat clinical and subjective conditions faster. It also emphasizes precise observation, utilization of natural
resources, and temporary suspension of disbelief to consider new perspectives and multiple viewpoints.
Rather than the formal analysis of historical causes of distress, the primary approach of brief therapy is to
help the client to view the present from a wider context and to utilize more functional understandings (not
necessarily at a conscious level). By becoming aware of these new understandings, successful clients will de
facto undergo spontaneous and generative change.
Brief therapy is often highly strategic, exploratory, and solution-based rather than problem-oriented. It is
less concerned with how a problem arose than with the current factors sustaining it and preventing change.
Brief therapists do not adhere to one "correct" approach, but rather accept that there being many paths, any
of which may or may not in combination turn out to be ultimately beneficial.
Founding proponents of Brief Therapy
Milton Erickson was a master of brief therapy, using clinical hypnosis as his primary tool. To a great extent
he developed this himself. His approach was popularized by Jay Haley, in the book "Uncommon therapy:
The psychiatric techniques of Milton Erickson M.D."
"The analogy Erickson uses is that of a person who wants to change the course of a river. if he opposes the
river by trying to block it, the river will merely go over and around him. But if he accepts the force of the
river and diverts it in a new direction, the force of the river will cut a new channel." (Haley, "Uncommon
therapy", p.24, emphasis in original)
Richard Bandler, the co-founder of neuro-linguistic programming, is another firm proponent of brief
therapy. After many years of studying Erickson's therapeutic work, he wrote:
"It's easier to cure a phobia in ten minutes than in five years... I didn't realize that the speed with which you
do things makes them last... I taught people the phobia cure. They'd do part of it one week, part of it the
next, and part of it the week after. Then they'd come to me and say "It doesn't work!" If, however, you do it
in five minutes, and repeat it till it happens very fast, the brain understands. That's part of how the brain
learns... I discovered that the human mind does not learn slowly. It learns quickly. I didn't know that." (Time
for a change, 1993, p.20)
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An Overview of Brief Therapy
Short-term counselling with lasting results
Brief Therapy is a model of therapy that focuses strongly on your present and future, as opposed to your
past. Traditional psychotherapy tends to focus on the past and looks for the cause of problems. In contrast,
Brief Therapy focuses on the solution to problems, which is why it is often called solution-oriented therapy.
Some Brief Therapy experts would go so far as to say they don't even need to know what the past problems
were to help the client. Although this is an extreme view, it does illustrate that Brief Therapy is firmly
rooted in the present with an eye toward changing the future.
The brief therapy solution-focused approach can be summed up in three stages,
according to Peller and Walter (1992):
1. Find out what you (the client) want
2. Determine what is currently working for you and do more of that
3. Do something different.
The simplicity of these stages belies their effectiveness. Consider, for example, the seemingly simple task of
finding out what you want to achieve in therapy. Most people go into therapy knowing all too well what
they don't want, what has been troubling them, or how frustrated they are by their problems. In the solutionfocused
model, our goal is to help you find out what you do want. Identifying your goal (or goals) is
perhaps the single most important thing you will do in your Brief Therapy sessions. In effect, the goals that
you articulate will guide you through the rest of your sessions, and they will be the mark against which you
will measure your success.
In the next stage, the emphasis is on finding out what parts of your life are working just fine. Brief
Therapists are strong adherents to the "if it ain't broke don't fix it" philosophy. When we find out what parts
of your life you're happy with, we can use them as a strong foundation upon which you can build an
improved lifestyle. In traditional therapy, by contrast, the focus is on diagnosing what is wrong with you or
what is not working for you. In Brief Therapy you will present your problems, but you will solve them by
using the strengths that you already have.
The last stage (Do something different) will help you when if you realize that one approach is not working
effectively. Because everyone has an almost infinite capacity for creative solutions (even if you don't realize
it now) we won't waste time on any approach that's not working for you. Since our time frame is measured
in weeks and months (as opposed to years) we want to find a solution that works in the shortest time
possible. Brief Therapy emphasizes the client as the expert. You will be in charge of your own therapy and
you will decide when you have attained your goals. Your therapist will listen to what you have to say, and
together you will develop goals and work collaboratively to find solutions.
Perhaps the most important thing to remember is that Brief Therapy is effective because people are capable
of change in a short amount of time.
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Strategic Family Therapy
From Wikipedia, the free encyclopedia
Strategic family therapy is a family-oriented therapy that involves a patient's daily family environment as a
major part of treatment. Pressure from family, society and peers can create rifts in even the strongest
families creating dysfunction.
Strategic family therapy seeks to address specific problems that can be addressed in a shorter time frame
than other therapy modalities. It is one of the major models of both family and brief psychotherapy. Jay
Haley of the the Strategic Family Therapy Center says that it is known as Strategic Therapy because "it is a
therapy where the therapist initiates what happens during therapy, designs a specific approach for each
person's presenting problem, and where the therapist takes responsibility for directly influencing people."
Strategic Family Therapy (Madanes and Haley) designs a strategy for each specific problem. Clear goals
set, symptoms deprived of their relationship-controlling function. Therapist controls the therapy. The goal
is to fix the problem creating disruption and preserving the family unit no matter what.
Every interaction is a struggle for control of the relationship's definition. Symmetrical (similar, often
competitive) vs. complementary (different, often counter responding) interactions. Meta communication and
repetitive interactions examined. Prescriptive and descriptive paradoxical assignments.
Madanes: "pretend techniques." Circular questioning. Positive connotation (as reframe of
symptomatic behaviour).
The goal is to fix the problem creating disruption and preserving the family unit no matter what.
Inspiration
The concept was inspired by the work of Milton Erickson, MD and Don Jackson, MD and has been
associated with (but not limited to) the work of Jay Haley and Cloe Madanes (founders of Family Therapy
Institute of Washington, DC in 1976), the Brief Therapy Team at the Mental Research Institute (John
Weakland, Dick Fisch, and Paul Watzlawick), the Milan School of Family Therapy, and the work of
Giorgio Nardone.
The theory of strategic family therapy evolved from many of the gains in early family therapy models that
were made by Milton Erickson and Don Jackson, with many other influences from such therapists as
Salvador Minuchin, Gregory Bateson, and other prominent early family therapists. Strategic family therapy
grew along with, and out of, other theories, most importantly, structural family therapy in the late 1960s and
early 1970s at the Mental Research Institute in Palo Alto, and later at the Philadelphia Child Guidance
Center. Many early family therapy theories were growing and influencing each other between the late 1950s
and late 1970s. At first glance these theories don’t seem to have direct connections,[according to whom?]
but many of the influential therapists of the time worked with each other and there was a natural give and
take between these theories.
Strategic family therapy was no exception to this organic growth of the theory. The main proponents and
creators of the theory were Jay Haley and Cloe Mandanes. Jay Haley had worked at the Mental Research
Institute in Palo Alto and the Philadelphia Child Guidance Center, and had worked directly with Erickson
and Minunchin. Haley and Mandanes took their knowledge of structural therapy and the ideas of how
families work on a structural level, but added ideas like making the therapist take more initiative and control
over the client’s problems.
The therapist seeks to identify the symptoms within the family that are the cause of the family’s
current problems, and fix these problems. In strategic family therapy the problems of the clients stem not
from their family’s behaviors toward the client, but instead it is the symptoms of the family that need to be
corrected. In strategic terms a symptom is “the repetitive sequence that keeps the process going. The
symptomatic person simply denies any intent to control by claiming the symptom is involuntary.”
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Haley Model
Jay Haley and Salvador Minuchin are considered the pioneers of strategic family therapy. In the 1950s and
1960s, Haley and other therapists began experimenting with alternative models of working with families
that relied on solution-focused techniques. The solution-focused approach was favored over traditional
psychoanalysis.
The therapy is based on the idea that people don't develop problems in isolation. Strategic therapy
implements techniques that meet the specific need of a family and their interaction.
Behavior Problems
Children between the ages eight and 17 are vulnerable to developing behavior problems. When this happens
it can throw family dynamics into a state of chaos. Strategic family therapy is a solution-oriented approach.
They focus on getting to the root of the problem rather than what caused it. The therapist works on helping
their clients turn their lives around by creating a carefully planned strategy, execution and monitoring
progress.
The therapy is based on five stages:
1. identify problems that can be solved,
2. establish goals,
3. create interventions that meet these objectives,
4. analyze the responses, and
5. examine the results.
The therapy emphasis is on the social situation not the individual. Solving problems, meeting family goals
and help change a person's dysfunctional behavior.
Family Interaction
Strategic family therapy considers the family unit as a system. Families function just like any other system.
They naturally establish rules and interactions that affect every member. When the affected family member's
problems are recognized and addressed, the entire family becomes part of the solution process. The idea
behind this method is that the family has the most influence on a person's life.
Therapy
All the family members participate within a safe, therapeutic setting. The therapist attempts to recreate
typical family interactions and conversation through provocative questioning techniques so that the
problems can be presented and addressed accordingly. It also give family members a chance to see how
their interactions and responses can contribute to a dysfunctional situation. The therapy works on helping
families discover their unique ability to solve their problems using internal resources they weren't aware
they had.
Concepts and processes
There are a number of concepts and processes that must be applied that are instrumental for SFT to succeed.
The initial session is one of these processes, and is broken down into five different parts, the brief social
stage, the problem stage, the interactional stage, goal-setting stage, and finally the task-setting stage.
The brief therapy stage seeks to observe the family’s interactions, create a calm and open mood for the
session, and attempts to get every family member to take part in the session.
The problem stage is where the therapist poses questions to the clients to determine what their problem is
and why they are there.
The interactional stage is where the family is urged to discuss their problem so the therapist can better
understand their issues and understand the underlying dynamics within the family. Some of the dynamics
that strategic family therapists seek to understand are: hierarchies within a family, coalitions between family
members, and communication sequences that exist.
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The goal-setting stage is used to highlight the specific issue that needs to be addressed, this issue is both
identified by the family members and the therapist. In addition when discussing the presenting problem
initially identified by the family, the family and the therapist work together to come up with goals to fix the
problem, and better define the parameters for attaining those goals.
The final stage of the initial session is the task-setting stage. In the task-setting stage the therapist wraps up
the session by coming up with concrete homework assignments or directives the family can do outside of
therapy to start to change their problems. Additional therapy sessions seek to further gain understanding to a
family’s problems, dynamics, and to dig deeper in addressing their needs through a confident, controlling,
and compassionate therapist.
Homework assignments
In SFT the assigning of homework or directives that take place outside of therapy is essential to the therapy
having a successful outcome. The underlying goal of the homework is to try to change the way the family
dynamics function around the presenting problem that was identified in session. Different from other
theories, the therapists take a more active and controlling approach in dealing with the family. They seek to
impose upon the family new directives that fundamentally alter the way the family functions. The therapists
use the initial session to gain trust and understanding with the family so that the therapists' commands to the
family are followed through in a manner where the family has confidence and trust in the therapists'
intentions.
There are some specific assumptions for family communications that SFT utilizes that are unique to SFT.
The communication models utilized are; “Every communication has a content report, and a relationship
command aspect.”, “Relationships are defined by commanding messages.”, “Relationships may be
described as symmetrical or complementary.”, and “Symmetrical relationships run the risk of becoming
competitive.” Once a therapist establishes the mechanisms of control, and command in a family, the
methods of communication can be further broken down by identifying double-binds in a family and
paradoxical injunctions. These are forms of unhealthy communication that send two messages at the same
time, and that contradict one another.
Since SFT seeks to change family dynamics on multiple levels that may contradict one another,
understanding how to achieve first-order change and second-order change are key for SFTs success. Firstorder
change, are those symptoms that are superficial and obvious to correct. For example pointing out body
language within the family. Second-order change would be the more difficult to achieve changes within the
very basic construct of a family structure, to bring about positive changes.
Interventions
Some less complicated but often used interventions in SFT would be, prescribing the symptom, relabeling,
and paradoxical interventions. Prescribing the symptom would be when the therapist attempts to exaggerate
a specific symptom within the family to help the family understand how damaging that symptom is to the
family. The relabeling intervention is done within the session by the therapist to change the connotation of
one symptom from negative to positive. In this way the family can view the symptom in a new context or
have a new conceptual understanding of the symptom.
Finally a paradoxical intervention is similar to prescribing the symptom, but is a more in depth intervention
than prescribing the symptom.
Initially the therapist tries to change the family’s low expectations to one where change within the family
can happen.
Second, the issue that the family wishes to fix is identified in a clear and concise manner.
Third, and in line with the goal-setting stage, the therapist seeks to get the family to agree to exactly what
their goals are in addressing their problem.
Fourth, the therapist comes up with very specific plans for the family to address their issue.
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Fifth, the therapist discredits whomever is the controlling figure of the issue.
Next the therapist replaces the controlling figure with their own authority and issues a new directive to fix
the family’s identified problem. The new directive for the family is usually to paradoxically do more of the
problem symptom, and thereby to highlight it more within the family.
Finally the therapist learns the outcome of the directive and seeks to push the paradox even further until the
family rebels, or change occurs within the family.
Hands-on approach
Strategic family therapy differs from many other models of therapy in that the therapist takes a more hands
on approach to fixing the family’s problems, and attempts to insert themselves into the problem as part of
the solution to the family’s problems. Most other models of therapy stay away from a format like this,
because of the inherent dangers within the practice, such as the family not following along with the
therapist, or the therapist losing sight of their proper role within the family. Strategic family therapy appears
to be a therapy that when utilized correctly can be used to address long standing family issues in a new and
imaginative manner, but comes along with many pitfalls if the therapist isn’t able to control the sessions as
the theory dictates.
Who Does it Help?
All families face challenges. ADD/ADHD, depression and substance abuse are a few of examples of issues
that can affect a family unit. If a child were dealing with any of the previous issues and had become
estranged from the family, the therapist would bring everyone together in a clinical setting to watch how
they interact. Then he could work closely with everyone in the family to implement and execute solutions to
help correct the dysfunctional behavior.
References
1.http://www.mri.org/strategic_family_therapy.html
2.Goldenbeg, Goldenberg, 2008
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Bowen’s Strategic Family Therapy
Contents
Introduction
Differentiation of Self
Triangles
The Nuclear Family Emotional Processes
The Family Projection Process
The Multigenerational Transmission Process
Sibling Position
Emotional Cutoff
Societal Emotional Processes
Normal Family Development
Family Disorders
Goals of Therapy
Techniques
Family Therapy with One Person
Introduction
The pioneers of family therapy recognized that current social and cultural forces shape our values about
ourselves and our families, our thoughts about what is "normal" and "healthy," and our expectations about
how the world works. However, Bowen was the first to realize that the history of our family creates a
template which shapes the values, thoughts, and experiences of each generation, as well as how that
generation passes down these things to the next generation.
Bowen was a medical doctor and the oldest child in a large cohesive family from Tennessee. He studied
schizophrenia, thinking the cause for it began in mother-child symbiosis, which created an anxious and
unhealthy attachment. He moved from studying dyads (two way relationships like parent-child and parentparent)
to triads (three way relationships like parent-parent-child and grandparent-parent-child) afterward.
At a conference organized by Framo, one of his students, he explained his theory of how families develop
and function, and presented as a case study his own family.
Bowen's theory focuses on the balance of two forces. The first is togetherness and the second is
individuality. Too much togetherness creates fusion and prevents individuality, or developing one's own
sense of self. Too much individuality results in a distant and estranged family.
Bowen introduced eight interlocking concepts to explain family development and functioning, each of
which is described below.
The family systems theory is a theory introduced by Dr. Murray Bowen that suggests that individuals
cannot be understood in isolation from one another, but rather as a part of their family, as the family
is an emotional unit. Families are systems of interconnected and interdependent individuals, none of whom
can be understood in isolation from the system.
The family system
According to Bowen, a family is a system in which each member has a role to play and rules to respect.
Members of the system are expected to respond to each other in a certain way according to their role, which
is determined by relationship agreements.
Within the boundaries of the system, patterns develop as certain family member's behaviour is caused by
and causes other family member's behaviours in predictable ways.
Maintaining the same pattern of behaviours within a system may lead to balance in the family system, but
also to dysfunction.
For example, if a husband is depressive and cannot pull himself together, the wife may need to take up more
responsibilities to pick up the slack. The change in roles may maintain the stability in the relationship, but it
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may also push the family towards a different equilibrium. This new equilibrium may lead to dysfunction as
the wife may not be able to maintain this overachieving role over a long period of time.
There are eight interlocking concepts in Dr. Bowen's theory:
1) Differentiation of self:
The variance in individuals in their susceptibility to depend on others for acceptance and approval.
2) Triangles:
The smallest stable relationship system. Triangles usually have one side in conflict and two sides in
harmony, contributing to the development of clinical problems.
3) Nuclear family emotional system:
The four relationship patterns that define where problems may develop in a family.
- Marital conflict
- Dysfunction in one spouse
- Impairment of one or more children
- Emotional distance
4) Family projection process:
The transmission of emotional problems from a parent to a child.
5) Multigenerational transmission process:
The transmission of small differences in the levels of differentiation between parents and their children.
6) Emotional cut-off:
The act of reducing or cutting off emotional contact with family as a way of managing unresolved
emotional issues.
7) Sibling position:
The impact of sibling position on development and behaviour.
8) Societal emotional process:
The emotional system governs behaviour on a societal level, promoting both progressive and regressive
periods in a society.
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1. Differentiation of Self
The first concept is Differentiation of Self, or the ability to separate feelings and thoughts.
Undifferentiated people can not separate feelings and thoughts; when asked to think, they are flooded with
feelings, and have difficulty thinking logically and basing their responses on that. Further, they have
difficulty separating their own from other's feelings; they look to family to define how they think about
issues, feel about people, and interpret their experiences.
Differentiation is the process of freeing yourself from your family's processes to define yourself. This
means being able to have different opinions and values than your family members, but being able to stay
emotionally connected to them. It means being able to calmly reflect on a conflicted interaction afterward,
realizing your own role in it, and then choosing a different response for the future.
Families and other social groups tremendously affect how people think, feel, and act, but individuals vary in
their susceptibility to a "group think" and groups vary in the amount of pressure they exert for conformity.
These differences between individuals and between groups reflect differences in people's levels of
differentiation of self. The less developed a person's "self," the more impact others have on his
functioning and the more he tries to control, actively or passively, the functioning of others. The basic
building blocks of a "self" are inborn, but an individual's family relationships during childhood and
adolescence primarily determine how much "self" he develops. Once established, the level of "self" rarely
changes unless a person makes a structured and long-term effort to change it.
People with a poorly differentiated "self" depend so heavily on the acceptance and approval of others that
either they quickly adjust what they think, say, and do to please others or they dogmatically proclaim
what others should be like and pressure them to conform. Bullies depend on approval and acceptance as
much as chameleons, but bullies push others to agree with them rather than their agreeing with others.
Disagreement threatens a bully as much as it threatens a chameleon. An extreme rebel is a poorly
differentiated person too, but he pretends to be a "self" by routinely opposing the positions of others.
A person with a well-differentiated "self" recognizes his realistic dependence on others, but he can stay
calm and clear headed enough in the face of conflict, criticism, and rejection to distinguish thinking rooted
in a careful assessment of the facts from thinking clouded by emotionality. Thoughtfully acquired principles
help guide decision-making about important family and social issues, making him less at the mercy of the
feelings of the moment. What he decides and what he says matches what he does. He can act selflessly, but
his acting in the best interests of the group is a thoughtful choice, not a response to relationship pressures.
Confident in his thinking, he can either support another's view without being a disciple or reject another
view without polarizing the differences. He defines himself without being pushy and deals with pressure to
yield without being wishy-washy.
Every human society has its well-differentiated people, poorly differentiated people, and people at many
gradations between these extremes. Consequently, the families and other groups that make up a society
differ in the intensity of their emotional interdependence depending on the differentiation levels of their
members. The more intense the interdependence, the less the group's capacity to adapt to potentially
stressful events without a marked escalation of chronic anxiety. Everyone is subject to problems in his work
and personal life, but less differentiated people and families are vulnerable to periods of heightened chronic
anxiety which contributes to their having a disproportionate share of society's most serious problems.
Example:
The description that follows is of how this triangle would play out for Michael, Martha and Amy if they
were (more) differentiated people.
Michael and Martha were quite happy during the first two years of their marriage. He liked making the
major decisions, but did not assume he knew "best." He always told Martha what he was thinking and he
listened carefully to her ideas. Their exchanges were usually thoughtful and led to decisions that respected
the vital interests of both people. Martha had always been attracted to Michael's sense of responsibility and
willingness to make decisions, but she also lived by a principle that she was responsible for thinking things
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through for herself and telling Michael what she thought. She did not assume Michael usually knew "best."
[Analysis: Because the level of stress on a marriage is often less during the early years, particularly before
the births of children and the addition of other responsibilities, the less adaptive moderately differentiated
marriage and the more adaptive well-differentiated marriage can look similar because the tension level is
low. Stress is necessary to expose the limits of a family's adaptive capacity.]
Martha conceived during the third year of the marriage and had a fairly smooth pregnancy. She had a few
physical problems, but dealt with them with equanimity. She was somewhat anxious about being an
adequate mother but felt she could manage these fears.
When she talked to Michael about her fears, she did not expect that he would solve them for her, but she
thought more clearly about her fears when she talked them out with him. He listened but was not
patronizing. He recognized his own fears about the coming changes in their lives and acknowledged them
to Martha.
[Analysis: The stresses associated with the real and anticipated changes of the pregnancy trigger some
anxiety in both Michael and Martha, but their interaction does not escalate the anxiety and make it chronic.
Martha had somewhat heightened needs and expectations of Michael, but she takes responsibility for
managing her anxiety and has realistic expectations about what he can do for her. Michael does not get
particularly reactive to Martha's expectations and recognizes he is anxious too. Each remains a resource to
the other.]
A female infant was born after a fairly smooth labor. They named her Amy. Martha weathered the delivery
fairly well and was ready to go home when her doctor discharged her. The infant care over the next few
months was physically exhausting for Martha, but she was not heavily burdened by anxieties about the baby
or about her adequacy as a mother. She continued to talk to Michael about her thoughts and feelings and
still did not feel he was supposed to do something to make her feel better. Although Michael had increasing
work pressures he remained emotionally available to her, even if only by phone at times. He worried about
work issues, but did not ruminate about them to Martha. When she asked how it was going, he responded
fairly factually and appreciated her interest. He occasionally wished Martha would not get anxious about
things, but realized she could manage. He was not compelled to "fix" things for her.
[Analysis: Sure of herself as a person, Martha is able to relate to Amy without feeling overwhelmed by
responsibilities and demands and without unfounded fears about the child's well-being. Sure of himself,
Michael can meet the reality demands of his job without feeling guilty that he is neglecting Martha. Each
spouse recognizes the pressure the other is under and neither makes a "federal case" about being neglected.
Each is sufficiently confident in the other's loyalty and commitment that neither needs much reassurance
about it. By the parents relating comfortably to each other, Amy is not triangled into marital tensions. She
does not have a void to fill in her mother's life related to distance between her parents.]
After a few months, Michael and Martha were able to find time to do some things by themselves. Martha
found that her anxieties about being a mother toned down and she did not worry much about Amy. As Amy
grew, Martha did not perceive her as an insecure child that needed special attention. She was positive about
Amy, but not constantly praising her in the name of reinforcing Amy's self-image. Michael and Martha
discussed their thoughts and feelings about Amy, but they were not preoccupied with her. They were
pleased to have her and took pleasure in watching her develop. Amy grew to be a responsible young child.
She sensed the limits of what was realistic for her parents to do for her and respected those limits. There
were few demands and no tantrums. Michael did not feel critical of Amy very often and Martha did not
defend Amy to him when he was critical. Martha figured Michael and Amy could manage their
relationship. Amy seemed equally comfortable with both of her parents and relished exploring her
environment.
[Analysis: Michael and Martha can see Amy as a separate and distinct person. The beginning differentiation
between Amy and her parents is evident when Amy is a young child. They have adapted quite successfully
to the anxieties they each experienced associated with the addition of a child and the increased demands in
Michael's work life. Their high levels of differentiation allow the three of them to be in close contact with
little triangling.]
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103

2. Triangles
Triangles are the basic units of systems. Dyads are inherently unstable, as two people will vacillate
between closeness and distance. When distressed or feeling intense emotions, they will seek a third person
to triangulate.
Think about a couple who has an argument, and afterward, one of the partners calls their parent or best
friend to talk about the fight. The third person helps them reduce their anxiety and take action, or calm
their strong emotions and reflect, or bolster their beliefs and make a decision.
People who are more undifferentiated are likely to triangulate others and be triangulated. People who
are differentiated cope well with life and relationship stress, and thus are less likely to triangulate others or
be triangulated.
Think of the person who can listen to the best friend's relationship problems without telling the friend
what to do or only validating the friend's view. Instead, the differentiated person can tell the best friend
"You know, you can be intimidating at those times..." or "I agree with you but you won't change your
partner; you either have to learn to accept this about them, or have to call this relationship quits..."
A triangle is a three-person relationship system. It is considered the building block or "molecule" of
larger emotional systems because a triangle is the smallest stable relationship system. A two-person
system (dyad) is unstable because it tolerates little tension before involving a third person. A triangle can
contain much more tension without involving another person because the tension can shift around three
relationships. If the tension is too high for one triangle to contain, it spreads to a series of "interlocking"
triangles.
Spreading the tension can stabilize a system, but nothing gets resolved. People's actions in a triangle reflect
their efforts to ensure their emotional attachments to important others, their reactions to too much intensity
in the attachments, and their taking sides in the conflicts of others.
Paradoxically, a triangle is more stable than a dyad, but a triangle creates an "odd man out," which is
a very difficult position for individuals to tolerate. Anxiety generated by anticipating or being the odd one
out is a potent force in triangles. The patterns in a triangle change with increasing tension. In calm periods,
two people are comfortably close "insiders" and the third person is an uncomfortable "outsider." The
insiders actively exclude the outsider and the outsider works to get closer to one of them.
Someone is always uncomfortable in a triangle and pushing for change. The insiders solidify their bond
by choosing each other in preference to the less desirable outsider. Someone choosing another person over
oneself arouses particularly intense feelings of rejection. If mild to moderate tension develops between the
insiders, the most uncomfortable one will move closer to the outsider. One of the original insiders now
becomes the new outsider and the original outsider is now an insider. The new outsider will make
predictable moves to restore closeness with one of the insiders.
At moderate levels of tension, triangles usually have one side in conflict and two sides in harmony. The
conflict is not inherent in the relationship in which it exists but reflects the overall functioning of the
triangle. At a high level of tension, the outside position becomes the most desirable. If severe conflict erupts
between the insiders, one insider opts for the outside position by getting the current outsider fighting with
the other insider. If the manoeuvring insider is successful, he gains the more comfortable position of
watching the other two people fight. When the tension and conflict subside, the outsider will try to regain an
inside position.
Triangles contribute significantly to the development of clinical problems. Getting pushed from an
inside to an outside position can trigger a depression or perhaps even a physical illness. Two parents
intensely focusing on what is wrong with a child can trigger serious rebellion in the child.
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Example:
Michael and Martha were extremely happy during the first two years of their marriage. Michael liked
making major decisions and Martha felt comforted by Michael's "strength." After some difficulty getting
pregnant, Martha conceived during the third year of the marriage, but it was a difficult pregnancy. She was
quite nauseous during the first trimester and developed blood pressure and weight gain problems as the
pregnancy progressed. She talked frequently to Michael of her insecurities about being a mother. Michael
was patient and reassuring, but also began to feel critical of Martha for being "childlike."
[Analysis: The pregnancy places more pressure on Martha and on the marital relationship. Michael is
outwardly supportive of Martha but is reactive to hearing about her anxieties. He views her as having a
problem.]
A female infant was born after a long labor. They named her Amy. Martha was exhausted and not ready to
leave the hospital when her doctor discharged her. Over the next few months, she felt increasingly
overwhelmed and extremely anxious about the well-being of the young baby. She looked to Michael for
support, but he was getting home from the office later and Martha felt that he was critical of her problems
coping and that he dismissed her worries about the child. There was much less time together for just
Michael and Martha and, when there was time, Michael ruminated about work problems. Martha became
increasingly preoccupied with making sure her growing child did not develop the insecurities she had. She
tried to do this by being as attentive as she could to Amy and consistently reinforcing her accomplishments.
It was easier for Martha to focus on Amy than it was for her to talk to Michael. She reacted intensely to his
real and imagined criticisms of her. Michael and Martha spent more and more of their time together
discussing Amy rather than talking about their marriage.
[Analysis: Martha is the most uncomfortable with the increased tension in the marriage. The growing
emotional distance in the marriage is balanced by Martha getting overly involved with Amy and Michael
getting overly involved with his work. Michael is in the outside position in the parental triangle and Martha
and Amy are in the inside positions.]
As Amy grew, she made increasing demands on her mother's time. Martha felt she could not give Amy
enough time, that Amy would never be satisfied. Michael agreed with Martha that Amy was too selfish and
resented Amy's temper tantrums when she did not get her way. However, if Michael got too critical of Amy,
Martha would defend Amy, telling Michael he was exaggerating. Yet, whenever tensions developed
between Martha and Amy, Martha would press Michael to spend more time with Amy to reassure her that
she was loved. He gave into Martha's pleas, but inwardly felt that they were following a policy of
appeasement that was making Amy more demanding. Michael felt that if Martha had his maturity, Amy
would be less of a problem, but, despite this attitude, Michael usually followed Martha's lead in relationship
to Amy.
[Analysis: When tension builds between Martha and Amy, Michael sides with Martha by agreeing that Amy
is the problem. The conflictual side of the triangle then shifts from between Martha and Amy to between
Michael and Amy. If the conflict gets too intense between Michael and Amy, Martha sides with Amy, the
conflict shifts into the marriage, and Amy gains the more comfortable outside position.]
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3. The Nuclear Family Emotional Processes
These are the emotional patterns in a family that continue over the generations.
Think about a mother who lived through The Great Depression, and taught her daughter to always
prepare for the worst case scenario and be happy simply if things are not that bad. The daughter
thinks her mother is wise, and so adopts this way of thinking. She grows up, has a son, and without
realizing it, models this way of thinking. He may follow or reject it, and whether he has a happy
or distressed relationship may depend on the kind of partner he finds.
Likewise, think of a daughter who goes to work for her father, who built his own father's small
struggling business into a thriving company. He is seen in the family as a great businessperson as he
did this by taking risks in a time of great economic opportunity. He teaches his daughter to take
risks, "spend money to make money," and assume a great idea will always be profitable. His
daughter may follow or reject her father's advice, and her success will depend on whether she faces
an economic boom or recession.
In both cases, the parent passes on an emotional view of the world (the emotional process), which is
taught each generation from parent to child, the smallest possible "unit" of family (the nuclear unit).
Reactions to this process can range from open conflict, to physical or emotional problems in one family
member, to reactive distancing (see below). Problems with family members may include things like
substance abuse, irresponsibility, depression....
The concept of the nuclear family emotional system describes four basic relationship patterns that govern
where problems develop in a family. People's attitudes and beliefs about relationships play a role in the
patterns, but the forces primarily driving them are part of the emotional system. The patterns operate in
intact, single-parent, step-parent, and other nuclear family configurations.
Clinical problems or symptoms usually develop during periods of heightened and prolonged family
tension. The level of tension depends on the stress a family encounters, how a family adapts to the stress,
and on a family's connection with extended family and social networks. Tension increases the activity of
one or more of the four relationship patterns. Where symptoms develop depends on which patterns are most
active. The higher the tension, the more chance that symptoms will be severe and that several people will be
symptomatic.
The four basic relationship patterns are:
Marital conflict
As family tension increases and the spouses get more anxious, each spouse externalizes his or her anxiety
into the marital relationship. Each focuses on what is wrong with the other, each tries to control the other,
and each resists the other's efforts at control.
Dysfunction in one spouse
One spouse pressures the other to think and act in certain ways and the other yields to the pressure. Both
spouses accommodate to preserve harmony, but one does more of it. The interaction is comfortable for both
people up to a point, but if family tension rises further, the subordinate spouse may yield so much selfcontrol
that his or her anxiety increases significantly. The anxiety fuels, if other necessary factors are
present, the development of a psychiatric, medical, or social dysfunction.
Impairment of one or more children
The spouses focus their anxieties on one or more of their children. They worry excessively and usually
have an idealized or negative view of the child. The more the parents focus on the child the more the child
focuses on them. He is more reactive than his siblings to the attitudes, needs, and expectations of the
parents. The process undercuts the child's differentiation from the family and makes him vulnerable to act
out or internalize family tensions. The child's anxiety can impair his school performance, social
relationships, and even his health.
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Emotional distance
This pattern is consistently associated with the others. People distance from each other to reduce the
intensity of the relationship, but risk becoming too isolated.
The basic relationship patterns result in family tensions coming to rest in certain parts of the family. The
more anxiety one person or one relationship absorbs, the less other people must absorb. This means that
some family members maintain their functioning at the expense of others. People do not want to hurt each
other, but when anxiety chronically dictates behaviour, someone usually suffers for it.
Example:
The tensions generated by Michael and Martha's interactions lead to emotional distance between them and
to an anxious focus on Amy. Amy reacts to her parents' emotional over involvement with her by making
immature demands on them, particularly on her mother.
[Analysis: A parent's emotional over involvement with a child programs the child to be as emotionally
focused on the parent as the parent is on the child and to react intensely to real or imagined signs of
withdrawal by the parent.]
When Amy was four years old, Martha got pregnant again. She wanted another child, but soon began to
worry about whether she could meet the emotional needs of two children. Would Amy be harmed by feeling
left out? Martha worried about telling Amy that she would soon have a little brother or sister, wanting to put
off dealing with her anticipated reaction as long as possible. Michael thought it was silly but went along
with Martha. He was outwardly supportive about the pregnancy, he too wanted another child, but he worried
about Martha's ability to cope.
[Analysis: Martha externalizes her anxiety onto Amy rather than onto her husband or rather than
internalizing it. Michael avoids conflict with Martha by supporting the focus on Amy and avoids dealing
with his own anxieties by focusing on Martha's coping abilities.]
Apart from her fairly intense anxieties about Amy, Martha's second pregnancy was easier than the first. A
daughter, Marie, was born without complications. This time Michael took more time away from work to
help at home, feeling and seeing that Martha seemed "on the edge." He took over many household duties
and was even more directive of Martha.
Martha was obsessed with Amy feeling displaced by Marie and gave in even more to Amy's demands for
attention. Martha and Amy began to get into struggles over how available Martha could be to her. When
Michael would get home at night, he would take Amy off her mother's hands and entertain her. He also
began feeling neglected himself and quite disappointed in Martha's lack of coping ability..
Martha had done some drinking before she married Michael and after Amy was born, but stopped
completely during the pregnancy with Marie. When Marie was a few months old, however, Martha began
drinking again, mostly wine during the evenings, and much more than in the past. She somewhat tried to
cover up the amount of drinking she did, feeling Michael would be critical of it. He was. He accused her of
not trying, not caring, and being selfish. Martha felt he was right. She felt less and less able to make
decisions and more and more dependent on Michael. She felt he deserved better, but also resented his
criticism and patronizing. She drank more, even during the day. Michael began calling her an alcoholic.
[Analysis: The pattern of sickness in a spouse has emerged, with Martha as the one making the most
adjustments in her functioning to preserve harmony in the marriage. It is easier for Martha to be the problem
than to stand up to Michael's diagnosing her and, besides, she feels she really is the problem.
As the pattern unfolds, Michael increasingly over functions and Martha increasingly under functions.
Michael is as allergic to conflict as Martha is, opting to function for her rather than risk the disharmony he
would trigger by expecting her to function more responsibly.]
By the time Amy and Marie were both in school, Martha reached a serious low point. She felt worthless and
out of control. She felt Michael did everything, but that she could not talk to him. Her doctor was concerned
about her physical health. Finally, Martha confided in him about the extent of her drinking. Michael had
been pushing her to get help, but Martha had reached a point of resisting almost all of Michael's directives.
However, her doctor scared her and she decided to go to Alcoholics Anonymous. Martha felt completely
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accepted by the A.A. group and greatly relieved to tell her story. She stopped drinking almost immediately
and developed a very close connection to her sponsor, an older woman. She felt she could be herself with
the people at A.A. in a way she could not be with Michael. She began to function much better at home,
began a part-time job, but also attended A.A. meetings frequently. Michael had complained bitterly about
her drinking, but now he complained about her preoccupation with her new found A.A. friends. Martha
gained a certain strength from her new friends and was encouraged by them "to stand up" to Michael. She
did. They began fighting frequently. Martha felt more like herself again. Michael was bitter.
[Analysis: Martha's involvement with A.A. helped her stop drinking, but it did not solve the family problem.
The level of family tension has not changed and the emotional distance in the marriage has not changed.
Because of "borrowing strength" from her A.A. group, Martha is more inclined to fight with Michael than to
go along and internalize the anxiety. This means the marital pattern has shifted somewhat from dysfunction
in a spouse to marital conflict, but the family has not changed in a basic way. In other words, Martha's level
of differentiation of self has not changed through her A.A. involvement, but her functioning has improved.]
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4. The Family Projection Process
This is an extension of The Nuclear Family Emotional Process in many ways. The family member
who "has" the "problem" is triangulated and serves to stabilize a dyad in the family.
Thus, the son who rejects his mother's pessimistic view may find his mother and sister become
closer, as they agree that he is immature and irresponsible. The more they share this view with him,
the more it makes him feel excluded and shapes how he sees himself. He may act in accord with
this view and behave more and more irresponsibly. He may reject it, constantly trying to "prove"
himself to be mature and responsible, but failing to gain his family's approval because they do not
attribute his successes to his own abilities ("He was so lucky that his company had a job opening
when he applied..." or "It's a good thing the loan officer felt sorry for him because he couldn't have
managed it without that loan..."). He might turn to substance abuse as he becomes more and more
irresponsible, or as he struggles with never meeting his family's expectations.
Similarly, the daughter who faces harsh economic times and is more fiscally conservative than her
father is seen by the parents as too rigid and dull. They join together to worry that she'll never be
happily married. She might accept this role and become a workaholic who has only superficial
relationships, or reject it and take wild risks that fail. In the end, she may become depressed as she
works more and more, or as she fails to live up to her father's reputation as a creative and successful
business person.
The family member who serves as the "screen" upon which the family "projects" this story will have
great trouble differentiating. It will be hard for the son or daughter above to hold their own opinions
and values, maintain their emotional strength, and make their own choices freely despite the family's
view of them.
The family projection process describes the primary way parents transmit their emotional problems to a
child. The projection process can impair the functioning of one or more children and increase their
vulnerability to clinical symptoms. Children inherit many types of problems (as well as strengths) through
the relationships with their parents, but the problems they inherit that most affect their lives are relationship
sensitivities such as heightened needs for attention and approval, difficulty dealing with expectations, the
tendency to blame oneself or others, feeling responsible for the happiness of others or that others are
responsible for one's own happiness, and acting impulsively to relieve the anxiety of the moment rather than
tolerating anxiety and acting thoughtfully. If the projection process is fairly intense, the child develops
stronger relationship sensitivities than his parents. The sensitivities increase a person's vulnerability to
symptoms by fostering behaviours that escalate chronic anxiety in a relationship system.
The projection process follows three steps:
(1) the parent focuses on a child out of fear that something is wrong with the child;
(2) the parent interprets the child's behaviour as confirming the fear; and
(3) the parent treats the child as if something is really wrong with the child.
These steps of scanning, diagnosing, and treating begin early in the child's life and continue. The parents'
fears and perceptions so shape the child's development and behaviour that he grows to embody their fears
and perceptions. One reason the projection process is a self-fulfilling prophecy is that parents try to "fix" the
problem they have diagnosed in the child; for example, parents perceive their child to have low self-esteem,
they repeatedly try to affirm the child, and the child's self-esteem grows dependent on their affirmation.
Parents often feel they have not given enough love, attention, or support to a child manifesting problems,
but they have invested more time, energy, and worry in this child than in his siblings. The siblings less
involved in the family projection process have a more mature and reality-based relationship with their
parents that fosters the siblings developing into less needy, less reactive, and more goal-directed people.
Both parents participate equally in the family projection process, but in different ways. The mother is
usually the primary caretaker and more prone than the father to excessive emotional involvement with one
or more of the children. The father typically occupies the outside position in the parental triangle, except
during periods of heightened tension in the mother-child relationship. Both parents are unsure of themselves
in relationship to the child, but commonly one parent acts sure of himself or herself and the other parent
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goes along. The intensity of the projection process is unrelated to the amount of time parents spend with a
child.
Example:
The case of Michael, Martha, and Amy illustrates the family projection process. Martha's anxiety about
Amy began before Amy was born. Martha feared she would transfer inadequacies she had felt as a child,
and still felt, to her own child. This was one reason Martha had mixed feelings about being a mother. Like
many parents, Martha felt a mother's most important task was to make a child feel loved. In the name of
showing love, she was acutely responsive to Amy's desires for attention. If Amy seemed bored and out of
sorts, Martha was there with an idea or plan. She believed a child's road to confidence and independence
was in the child feeling secure about herself. Martha did not recognize how sensitive she was to any sign in
Amy that she might be upset or troubled and how quickly she would move in to fix the problem.
Martha loved Amy deeply. She and Amy often seemed like one person in the way they were attuned to each
other. As a very small toddler, Amy was as sensitive to her mother's moods and wants as Martha was to
Amy's moods and wants.
[Analysis: Martha's excessive involvement programs Amy to want much of her mother's attention and to be
highly sensitive to her mother's emotional state. Both mother and child act to reinforce the intense
connection between them.]
At some point in the unfolding of their relationship, Martha began to feel irritated at times by what Martha
regarded as Amy's "insatiable need" for attention. Martha would try to distance from Amy's neediness, but
not very successfully because Amy had ways to involve her mother with her. Martha flip-flopped between
pleading with and cajoling Amy one minute and being angry at and directive of her the next. It seemed to
lock them together even more tightly. Martha looked to Michael to take over at such times. Despite calling
Amy's need for attention insatiable, Martha felt Amy really needed more of her time and she faulted herself
for not being able to give enough. She wanted Michael to help with the task. It bothered Martha if Amy
seemed upset with her. Amy's upsets triggered guilt in Martha and a fear that they were no longer close
companions. She wanted to soothe Amy and feel close to her.
[Analysis: Martha blames Amy for the demands she makes on her, but at the same time feels she is failing
Amy. Martha tries to "fix" Amy's problem by doing more of what she has already been doing and solicits
Michael's help in it. Martha is meeting many of her own needs for emotional closeness and companionship
through Amy, thus gets very distressed if Amy seems unhappy with her. The marital distance accentuates
Martha's need for Amy.]
Martha's second pregnancy changed a reasonably manageable situation into an unmanageable one. The
dilemma of meeting the needs of both children seemed impossible to Martha. She felt Amy was already
showing signs of "inheriting" her insecurities. How had she failed her?
When it was time for Amy to start school, Martha sought long conferences with the kindergarten teacher to
plan the transition. If Amy balked at going to school, Martha became frightened, angry, exasperated, and
guilty. The kindergarten teacher felt she understood children like Amy and took great interest in her. Amy
was bright, thrived on the teacher's attention, and performed very well in school. Martha had none of these
fears when Marie started school and, not surprisingly, none of the school transition problems occurred with
her. Marie did not seem to require so much of the teacher's attention; she just pursued her interests.
As Amy progressed through grade school, her adjustment to school seemed to depend heavily on the teacher
she had in a particular year. If the teacher seemed to take an unusual interest in her, she performed very
well, but if the teacher treated her as one of the group, she would lose interest in her work. Martha focused
on making sure Amy got the "right" teacher whenever possible. Marie's performance did not depend on a
particular teacher.
[Analysis: Martha's difficulty being a "self" with her children is reflected in her feeling inordinately
responsible for the happiness of both children. This makes it extremely difficult for her to interact
comfortably with two children. Amy transfers the relationship intensity she has with her mother to her
teachers. When a teacher makes her special, Amy performs very well, but without that type of relationship,
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Amy performs less well. Marie is less involved with her mother and, consequently, her performance is less
dependent on the relationship environment at school and at home.]
If Amy complained about the ways other kids treated her in school, Martha and Michael would talk to her
about not being so sensitive, telling her she should not care so much about what other people think. If Amy
had a special friend, she was extremely sensitive to that friend paying attention to another little girl. Martha
lectured Amy about being less sensitive but also planned outings and parties designed to help Amy with her
friendships. Michael criticized Martha for this, saying Amy should work out these problems for herself, but
he basically went along with all of Martha's efforts.
[Analysis: The parents' words do not match their actions. They lecture Amy about being less sensitive, but
the frequent lectures belie their own anxieties about such issues and their doubts about Amy's ability to
cope. Amy's sensitivity to being in the outside position in a triangle with her playmates reflects her
programming for such relationship sensitivities in the parental triangle.]
Martha and Amy had turmoil in their relationship during Amy's elementary school years, but things got
worse in middle school. Amy began having academic problems and complained about feeling lost in the
larger school. She seemed unhappy to Martha. Martha talked to Michael and to the paediatrician about
getting therapy for Amy. They hired tutors for Amy in two of her subjects, even though they knew that part
of the problem was Amy not working hard in those subjects. When Amy's grades did not improve, Michael
criticized her for not taking advantage of the help they were giving and not appreciating them as parents.
Martha scolded Michael for being too hard on Amy, but inwardly she felt even more critical of her than
Michael did. She had worked hard to prevent these very problems in Amy. How could Amy disappoint her
so much? In the summers when there were no academic pressures, Martha and Amy got along much better.
[Analysis: Commonly parents get critical of a child with whom they have been excessively involved if the
child's performance drops. They push for the child to have therapy or tutors rather than think about the
changes they themselves need to make. Medicine, psychiatry, and the larger society usually reinforce the
child focus by defining the problem as being in the child and by often implying that the parents are not
attentive and caring enough.]
The big changes occurred when Amy started high school. Martha felt Amy was telling her less of what was
happening in her life and that she was more sullen and withdrawn. Amy also had a new group of girlfriends
that seemed less desirable to Martha. Amy had also found boys. Martha and Amy got into more frequent
conflicts. Amy felt controlled by her parents, not given the freedom to make her own decisions, pick her
own friends. She resented her mother's obvious intrusions into her room when she was out. She began lying
to her mother in an effort to evade her rules. Martha was no longer drinking herself at this point, but worried
that Amy was using drugs and alcohol. She challenged Amy about it, but her challenges were met with
denials.
When Martha felt particularly overwhelmed by the situation, Michael would step in and try to lay down the
law to Amy. He accused Amy of not appreciating all they had done for her and of deliberately trying to hurt
them. He wanted to know "why" she disobeyed them. Amy would lash back at her father in these
discussions, at which point Martha would intervene. Amy stayed away from the house more, told her
parents less and less, and got in with a fairly wild crowd. She acted out some of her parents worst fears, but
did not feel particularly good about herself and about what she was doing. Amy felt alienated from her
parents. The parents' focus on her deteriorating grades included lectures and groundings, but Amy easily
evaded these efforts to control and change her.
[Analysis: The more intense the family projection process has been, the more intense the adolescent
rebellion. Parents typically blame the rebellion on adolescence, but the parents reactivity to the child fuels
the rebellion as much as the child's reactivity. When the parents demand to know "why" Amy acts as she
does, they place the problem in Amy. Similarly, parents often blame the influence of the peer group, which
also places the problem outside themselves. Peers are an important influence, but a child's vulnerability to
peer pressure is related to the intensity of the family process. The intense family process closes down
communication and isolates Amy from the family. This is why a child who is very intensely connected to
her parents can feel distant from them. The siblings who are less involved in the family problem navigate
adolescence more smoothly.]
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Michael and Martha became increasingly critical of Amy, but also latched onto any signs she might be
doing a little better. They gave her her own phone, bought the clothes she "just had to have," and gave her a
car for her sixteenth birthday. Many of these things were done in the name of making Amy feel special and
important, hoping that would motivate her to do better. Throughout all the turmoil surrounding Amy, Marie
presented few problems.
[Analysis: The parents' permissiveness is just as important in perpetuating the problems in Amy as the
critical focus on her. As a teenager, Amy is just as critical of her parents as they are of her. Marie is a more
mature person than Amy, but she is not free of the family problem; for example, she sides with her parents
in blaming Amy for the family turmoil.]
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5. The Multigenerational Transmission Process
This process entails the way family emotional processes are transferred and maintained over the
generations. This captures how the whole family joins in The Family Projection Process, for example, by
reinforcing the beliefs of the family. As the family continues this pattern over generations, the also refer
back to previous generations ("He's just like his Uncle Albert - he was always irresponsible too" or "She's
just like your cousin Jenny - she was divorced four times.").
The concept of the multigenerational transmission process describes how small differences in the levels of
differentiation between parents and their offspring lead over many generations to marked differences in
differentiation among the members of a multigenerational family. The information creating these
differences is transmitted across generations through relationships. The transmission occurs on several
interconnected levels ranging from the conscious teaching and learning of information to the automatic and
unconscious programming of emotional reactions and behaviours. Relationally and genetically transmitted
information interact to shape an individual's "self."
The combination of parents actively shaping the development of their offspring, offspring innately
responding to their parents' moods, attitudes, and actions, and the long dependency period of human
offspring results in people developing levels of differentiation of self similar to their parents' levels.
However, the relationship patterns of nuclear family emotional systems often result in at least one member
of a sibling group developing a little more "self" and another member developing a little less "self" than the
parents.
The next step in the multigenerational transmission process is people predictably selecting mates with levels
of differentiation of self that match their own. Therefore, if one sibling's level of "self" is higher and another
sibling's level of "self" is lower than the parents, one sibling's marriage is more differentiated and the other
sibling's marriage is less differentiated than the parents' marriage. If each sibling then has a child who is
more differentiated and a child who is less differentiated than himself, one three generational line becomes
progressively more differentiated (the most differentiated child of the most differentiated sibling) and one
line becomes progressively less differentiated (the least differentiated child of the least differentiated
sibling). As these processes repeat over multiple generations, the differences between family lines grow
increasingly marked.
Level of differentiation of self can affect longevity, marital stability, reproduction, health, educational
accomplishments, and occupational success. This impact of differentiation on overall life functioning
explains the marked variation that typically exists in the lives of the members of a multigenerational family.
The highly differentiated people have unusually stable nuclear families and contribute much to society; the
poorly differentiated people have chaotic personal lives and depend heavily on others to sustain them. A key
implication of the multigenerational concept is that the roots of the most severe human problems as well as
of the highest levels of human adaptation are generations deep. The multigenerational transmission process
not only programs the levels of "self" people develop, but it also programs how people interact with others.
Both types of programming affect the selection of a spouse. For example, if a family programs someone to
attach intensely to others and to function in a helpless and indecisive way, he will likely select a mate who
not only attaches to him with equal intensity, but one who directs others and make decisions for them.
Example:
The multigenerational transmission process helps explain the particular patterns that have played out in the
nuclear family of Michael, Martha, Amy, and Marie. Martha is the youngest of three daughters from an
intact Midwestern family. From her teen years on, Martha did not feel especially close to either of her
parents, but especially to her mother. She experienced her mother as competent and caring but often
intrusive and critical. Martha felt she could not please her mother.
Her sisters seemed to feel more secure and competent than Martha. She asked herself how she could grow
up in a seemingly "normal" family and have so many problems, and answered herself that there must be
something wrong with her. When she faced important dilemmas in her life and had decisions to make, her
mother got involved and strongly influenced Martha's choices. Her mother said Martha should make her
own decisions, but her mother's actions did not match her words. One of her mother's biggest fears was that
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Martha would make the wrong decision. In time, Martha's sisters came to view her much like their mother
did and treated her as the baby of the family, as one needing special guidance. Martha's father was
sympathetic with her one-down position in the family, but he distanced from family tensions.
Martha detested herself for needing the acceptance and approval of others to function effectively and for
feeling she could not act more independently. She worried about making the wrong decision and turned
frequently to her mother for help.
[Analysis: The primary relationship pattern in Martha's family of origin was impairment of one or more
children, and the projection process focused primarily on Martha. The mother's over functioning promoted
Martha's under functioning, but Martha largely blamed herself for her difficulties making decisions and
functioning independently. Martha's intense need for approval and acceptance reflected the high level of
involvement with her mother. She managed the intensity with her mother with emotional distance. These
basic patterns were later replicated in her marriage and with Amy.]
Martha's mother is the oldest child in her family and functioned as a second parent to her three younger
siblings. Martha's mother's mother became a chronic invalid after her last child was born. As a child,
Martha's mother functioned as a second mother in her family and, with the encouragement of her father, did
much of the caretaking of her invalid mother. Martha's mother basked in the approval she gained from both
of her parents, especially from her father. Her father was often critical of his wife, insisting she could do
more for herself if she would try. Martha's grandmother responded to the criticism by taking to bed, often
for days at a time. Martha's mother learned to thrive on taking care of others and being needed.
[Analysis: Martha's mother probably had almost as intense an involvement with her parents as she
subsequently had with Martha, but the styles of the involvements were different. Two relationship patterns
dominated Martha's mother's nuclear family: dysfunction in one spouse and over involvement with a child.
Martha's mother was intensely involved in the triangles with her parents and younger siblings and in the
position of over functioning for others. In other words, she learned to meet her strongly programmed needs
for emotional closeness by taking care of others, a pattern that played out with Martha.]
Michael grew up as an only child in an intact family from the Pacific Northwest. He met Martha when he
attended college in the Midwest. Michael's mother began having frequent bouts of serious depression about
the time he started grade school. She was twice hospitalized psychiatrically, once after an overdose of
tranquilizers. Michael felt "allergic" to his mother's many problems and kept his distance from her,
especially during his adolescence. He cared about her and felt she would help him in any way she could, but
viewed her as helpless and incompetent. He resented her "not trying harder." He had a reasonably
comfortable relationship with his father, but felt his father made the family situation worse by opting for
"peace at any price." It was easier for his father to give in to his wife's sometimes childish demands than to
draw a line with her.
Michael related to his mother almost exactly like his father did. His mother expressed resentment about her
husband's passivity. She accused him of not really caring about her, only doing things for her because she
demanded it. Michael's mother worshiped Michael and was jealous of interests and people that took him
away from her.
[Analysis: Interestingly, Michael's parental triangle was similar to Martha's mother's parental triangle. His
mother was intensely involved with him and it programmed Michael both to need this level of emotional
support from the important female in his life, but also to react critically to the female's neediness. Michael's
parental triangle also fostered a belief that he knew best.]
Michael's mother had been a "star" in her family when she was growing up. She was an excellent student
and athlete. She had a very conflictual relationship with her mother and an idealized view of her father. She
met Michael's father when they were both in college. He was two years older than she and when he
graduated, she quit school to marry him. Her parents were very upset about the decision. Michael's father
had been at loose ends when he met his future wife, but she was what he needed. He built a very successful
business career with her emotional support. He functioned higher in his work life than in his family life.
[Analysis: Michael's father functioned on a higher level in his business life than in his family life, a
discrepancy that is commonly present in people with mid-range levels of differentiation of self.]
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6. Sibling Position
Bowen stressed sibling order, believing that each child had a place in the family hierarchy, and thus was
more or less likely to fit some projections. The oldest sibling was more likely to be seen as overly
responsible and mature, and the youngest as overly irresponsible and immature for example.
Think of the oldest sibling who grows up and partners with a person who was also an oldest sibling.
They may be drawn to each other because both believe the other is mature and responsible.
Alternately, an oldest sibling might have a relationship with someone who was a youngest sibling. When
one partner behaves a certain way, the other might think "This is exactly how my older/younger sibling used
to act."
Bowen theory incorporates the research of psychologist Walter Toman as a foundation for its concept of
sibling position. Bowen observed the impact of sibling position on development and behaviour in his family
research. However, he found Toman's work so thorough and consistent with his ideas that he incorporated it
into his theory. The basic idea is that people who grow up in the same sibling position predictably have
important common characteristics. For example, oldest children tend to gravitate to leadership positions and
youngest children often prefer to be followers. The characteristics of one position are not "better" than those
of another position, but are complementary. For example, a boss who is an oldest child may work unusually
well with a first assistant who is a youngest child. Youngest children may like to be in charge, but their
leadership style typically differs from an oldest's style.
Toman's research showed that spouses' sibling positions affect the chance of their divorcing. For example, if
an older brother of a younger sister marries a younger sister of an older brother, less chance of a divorce
exists than if an older brother of a brother marries an older sister of a sister. The sibling or rank positions are
complementary in the first case and each spouse is familiar with living with someone of the opposite sex. In
the second case, however, the rank positions are not complementary and neither spouse grew up with a
member of the opposite sex. An older brother of a brother and an older sister of a sister are prone to battle
over who is in charge; two youngest children are prone to struggle over who gets to lean on whom.
People in the same sibling position, of course, exhibit marked differences in functioning. The concept of
differentiation can explain some of the differences. For example, rather than being comfortable with
responsibility and leadership, an oldest child who is anxiously focused on may grow up to be markedly
indecisive and highly reactive to expectations. Consequently, his younger brother may become a "functional
oldest," filling a void in the family system. He is the chronologically younger child, but develops more
characteristics of an oldest child than his older brother. A youngest child who is anxiously focused on may
become an unusually helpless and demanding person. In contrast, two mature youngest children may
cooperate extremely effectively in a marriage and be at very low risk for a divorce.
Middle children exhibit the functional characteristics of two sibling positions. For example, if a girl has an
older brother and a younger sister, she usually has some of the characteristics of both a younger sister of a
brother and an older sister of a sister. The sibling positions of a person's parents are also important to
consider. An oldest child whose parents are both youngests encounters a different set of parental
expectations than an oldest child whose parents are both oldests.
Example:
Knowledge of Michael and Martha
Michael is an only child who, like Martha's mother, was raised in a family with a mother who had many
problems. Michael's father is the younger brother of a sister and his mother is the older sister of a brother.
Michael's mother was the more focused on child when she was growing up, a focus that took the form of
high performance expectations coupled with considerable family anxiety about her ability to meet those
expectations. In many ways, Michael's Martha's sibling positions and those of their parents adds to the
understanding of how things played out in their lives. Martha is the youngest of three girls and was the most
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intensely focused on child in her family. Furthermore, Martha's mother is the oldest of four siblings and was
raised in a family with a mother who was a chronic invalid. Martha's mother was a not very well
differentiated oldest daughter. Her life energy focused on taking care of and directing others to the point that
she unwittingly undermined the functioning of her youngest daughter. Martha played out the opposite side
of the problem by becoming an indecisive, helpless, and mostly self-blaming person. Martha's father was
the youngest brother in a family of five children.
[Analysis: Martha, by virtue of her mother's focus on her, has the moderately exaggerated traits of a
youngest child. Furthermore, her father being a youngest and her mother an oldest favored her mother's
functioning setting the tone in the family. In other words, her mother was quicker to act than her father in
face of problems.] father was quite dependent on his wife for affirmation and direction, even when she was
depressed and overwhelmed. As an only child, the pattern of functioning of the triangle with his parents was
the major influence on Michael's development. His emotional programming in that triangle made him a
perfect fit with Martha.
[Analysis: Michael's only child position makes him a somewhat reluctant leader in his nuclear family. He
wants Martha to function better and to take more responsibility. He is unhappy feeling the pressure himself.
Despite being in the one-up position in the marriage, he is as dependent on Martha as his father was
dependent on his wife.]
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7. Emotional Cut-off
This refers to an extreme response to The Family Projection Process. This entails a complete or almostcomplete
separation from the family. The person will have little, if any, contact, and may look and feel
completely independent from the family. However, people who cut off their family are more likely to repeat
the emotional and behavioural patterns they were taught.
In some cases, they model the same values and coping patterns in their adult family that they were
taught in their childhood family without realizing it. They do not have another internal model for
how families live, and so it is very hard to "do something different." Thus, some parents from
emotionally constrained families may resent how they were raised, but they do not know how to be
"emotionally free" and raise a family as they believe other families would.
In other cases, they consciously attempt to be very different as parents and partners; however, they
fail to realize the adaptive characteristics of their family and role models, as well as the
compensatory roles played in a complex family. Thus, some parents from emotionally constrained
childhood families might discover ways to be "emotionally unrestrained" in their adult families, but
may not recognize some of the problems associated with being so emotionally unrestrained, or the
benefits of being emotionally constrained in some cases. Because of this, Bowen believed that
people tend to seek out partners who are at about the same level of individuation.
The concept of emotional cut-off describes people managing their unresolved emotional issues with parents,
siblings, and other family members by reducing or totally cutting off emotional contact with them.
Emotional contact can be reduced by people moving away from their families and rarely going home, or it
can be reduced by people staying in physical contact with their families but avoiding sensitive issues.
Relationships may look "better" if people cut-off to manage them, but the problems are dormant and not
resolved.
People reduce the tensions of family interactions by cutting off, but risk making their new relationships too
important. For example, the more a man cuts off from his family of origin, the more he looks to his spouse,
children, and friends to meet his needs. This makes him vulnerable to pressuring them to be certain ways for
him or accommodating too much to their expectations of him out of fear of jeopardizing the relationship.
New relationships are typically smooth in the beginning, but the patterns people are trying to escape
eventually emerge and generate tensions. People who are cut off may try to stabilize their intimate
relationships by creating substitute "families" with social and work relationships.
Everyone has some degree of unresolved attachment to his or her original family, but well-differentiated
people have much more resolution than less differentiated people. An unresolved attachment can take many
forms. For example, (1) a person feels more like a child when he is home and looks to his parents to make
decisions for him that he can make for himself, or (2) a person feels guilty when he is in more contact with
his parents and that he must solve their conflicts or distresses, or (3) a person feels enraged that his parents
do not seem to understand or approve of him. An unresolved attachment relates to the immaturity of both
the parents and the adult child, but people typically blame themselves or others for the problems.
People often look forward to going home, hoping things will be different this time, but the old interactions
usually surface within hours. It may take the form of surface harmony with powerful emotional
undercurrents or it may deteriorate into shouting matches and hysterics. Both the person and his family may
feel exhausted even after a brief visit. It may be easier for the parents if an adult child keeps his distance.
The family gets so anxious and reactive when he is home that they are relieved when he leaves. The siblings
of a highly cut-off member often get furious at him when he is home and blame him for upsetting the
parents. People do not want it to be this way, but the sensitivities of all parties preclude comfortable contact.
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Example:
Neither Michael nor Martha wanted to live near their families. When Michael got a good job offer on the
East coast, both of them were eager to move east. They told their families they were moving away because
of Michael's great job offer, but they welcomed the physical distance from their families. Michael felt guilty
about living far away from his parents and his parents were upset about it, especially Michael's mother.
Michael called home every weekend and managed to combine business trips with brief stays with his
parents. He did not look forward to the phone calls and usually felt depressed after them. He felt as if his
mother deliberately put him on "guilt trips" by emphasizing how poorly she was doing and how much she
missed seeing him. She never failed to ask if his company could transfer him closer to home. It was much
less depressing for Michael to talk to his father, but they talked mostly about Michael's job and what his
Dad was doing in retirement.
[Analysis: Michael blamed his mother for the problems in their relationship and, despite his guilt, felt
justified distancing from her. People commonly have a "stickier" unresolved emotional attachment with
their mothers than with their fathers because the way a parental triangle usually operates is that the mother
is too involved with the child and the father is in the outside position.] In the early years, Martha would
sometimes participate in Michael's phone calls home but, as her problems mounted, she usually left the calls
to Michael. Michael did not say much to his parents about Martha's drinking or about the tensions in their
marriage. He would report on how the kids were doing. Michael, Martha, and the kids usually made one
visit to Michael's parents each year. They did not look forward to the four days they would spend there, but
Michael's mother thrived on having them. Martha never said anything to Michael's parents about her
drinking or the marital tensions, but she talked at length about Amy to Michael's mother. Amy often
developed middle ear infections during or soon after these trips.
[Analysis: Frequently one or more family members get sick leading up to, during, or soon after trips home.
Amy was more vulnerable because of the anxious focus on her.] Martha followed a pattern similar to
Michael's in dealing with her family. One difference was that her parents came east fairly often. When they
came, Martha's mother would get more worried about Martha and critical of both her drinking and of how
she was raising Amy. Martha dreaded these exchanges with her mother and complained to Michael for days
after her parents returned home. Deep down, however, Martha felt her mother was right about her
deficiencies. Martha's mother pumped Michael for information about Martha when Martha was reluctant to
talk. Michael was all too willing to discuss Martha's perceived shortcomings with her mother.
[Analysis: Given the striking parallels between the unresolved issues in Michael's relationship with his
family, Martha's relationship with her family, and the issues in their marriage, emotional cut-off clearly did
not solve any problems. It simply shifted the problems to their marital relationship and to Amy.]
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8. Societal Emotional Processes
These processes are social expectations about racial and class groups, the behaviours for each gender, the
nature of sexual orientation... and their effect on the family. In many ways, this is like The Family
Projection Process scaled up to the level of a society as a whole. Families that deal with prejudice,
discrimination, and persecution must pass on to their children the ways they learned to survive these factors.
The coping practices of the parents and extended family may lead to more or less adaptive emotional health
for the family and its members.
Each concept in Bowen theory applies to nonfamily groups, such as work and social organizations. The
concept of societal emotional process describes how the emotional system governs behaviour on a societal
level, promoting both progressive and regressive periods in a society. Cultural forces are important in how a
society functions but are insufficient for explaining the ebb and flow in how well societies adapt to the
challenges that face them. Bowen's first clue about parallels between familial and societal emotional
functioning came from treating families with juvenile delinquents. The parents in such families give the
message, "We love you no matter what you do." Despite impassioned lectures about responsibility and
sometimes harsh punishments, the parents give in to the child more than they hold the line. The child rebels
against the parents and is adept at sensing the uncertainty of their positions. The child feels controlled and
lies to get around the parents. He is indifferent to their punishments. The parents try to control the child but
are largely ineffectual.
Bowen discovered that during the 1960s the courts became more like the parents of delinquents. Many in
the juvenile court system considered the delinquent as a victim of bad parents. They tried to understand him
and often reduced the consequences of his actions in the hope of effecting a change in his behaviour. If the
delinquent became a frequent offender, the legal system, much like the parents, expressed its
disappointment and imposed harsh penalties. This recognition of a change in one societal institution led
Bowen to notice that similar changes were occurring in other institutions, such as in schools and
governments. The downward spiral in families dealing with delinquency is an anxiety-driven regression in
functioning. In a regression, people act to relieve the anxiety of the moment rather than act on principle and
a long-term view. A regressive pattern began unfolding in society after World War II. It worsened some
during the 1950s and rapidly intensified during the 1960s. The "symptoms" of societal regression include a
growth of crime and violence, an increasing divorce rate, a more litigious attitude, a greater polarization
between racial groups, less principled decision-making by leaders, the drug abuse epidemic, an increase in
bankruptcy, and a focus on rights over responsibilities.
Human societies undergo periods of regression and progression in their history. The current regression
seems related to factors such as the population explosion, a sense of diminishing frontiers, and the depletion
of natural resources. Bowen predicted that the current regression would, like a family in a regression,
continue until the repercussions stemming from taking the easy way out on tough issues exceeded the pain
associated with acting on a long-term view. He predicted that will occur before the middle of the twentyfirst
century and should result in human beings living in more harmony with nature.
Example:
It is more difficult for families to raise children in a period of societal regression than in a calmer period. A
loosening of standards in society makes it more difficult for less differentiated parents like Michael and
Martha to hold a line with their children. The grade inflation in many school systems makes it easier for
students to pass grades with less work. In the litigious climate, if schools try to hold the line on what they
can realistically do for their students, they often face lawsuits from irate parents.
The prevalence of drug and alcohol abuse gives parents more things to worry about with their adolescents.
The current societal regression is characterized by an increased child focus in the culture. Much anxiety
exists about the future generation. Parents are criticized for being too busy with their own pursuits to be
adequately available to their children, both to support them and to monitor their activities. When children
like Amy report that they feel distant from their parents and alienated from their values, the parents' critics
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fail to appreciate the emotional intensity that generates such alienation. The critics prod the parents to do
more of what they have already been doing.
People who advocate more focus on the children cite the many problems young people are having as
justification for their position. Using the child's problems as justification for increasing the focus on them is
precisely what the child focused parents have been doing all along. An increase in the problems young
people are having is part of an emotional process in society as a whole. A more constructive direction would
be for people to examine their own contributions to societal regression and to work on themselves rather
than focus on improving the future generation.
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Murray Bowen’s approach operates on the premise that a family can best be understood when it is
analyzed from at least a three-generation perspective, because a predictable pattern of interpersonal
relationships connects the functioning of family members across generations.
According to Bowen, the cause of an individual's problems can be understood only by viewing the role of
the family as an emotional unit. A basic assumption in Bowen family therapy is that unresolved emotional
fusion (or attachment) to one's family must be addressed if one hopes to achieve a mature and unique
personality.
Areas of assessment
Bowen (1966, 1976) identifies eight key concepts as being central to his theory that can be grouped into
four areas of assessment:
1) Spousal relationships
2) de-triangulation (triangulation)
3) differentiation (differentiation of the self, sibling position, emotional cutoff).
4) emotional systems (the nuclear family emotional system, societal regression, the family projection
process and the multigenerational transmission process, sibling position),
Of these, the major contributions of Bowen's theory are the core concepts of differentiation of the self and
triangulation.
He focused on helping families develop individual identities for each member while maintaining a sense of
closeness and togetherness with their families.
1) Spousal relationships
Bowen paid attention to the spousal relationship and the definition and clarification of the couple's
relationship.
Interrelations emphasized more than components;
system wide ripples ("these cause each other") emphasized more than linearity (this causes that).
Whatever its components, unresolved stress between parents reverberates down through all family interrelations
and normally results in coalitions, emotional parent-child alignments against the other parent and
perhaps other children.
Example: Mom is a rageaholic, so when she explodes, Dad and Brother console one another and perhaps
agree that she's nuts.
A linear approach would emphasize Mom's upbringing and lack of anger management skills and thereby
ignore the coalition process itself and reinforce its tendency to scapegoat,
whereas a systems approach would focus on the present-time context of Mom's explosions, looking at the
interactions leading up to it and encouraging Dad and Mom to work out new, non escalating ways to talk
and negotiate--perhaps in couples therapy--rather than blaming her or him or failing to confront and defuse
alliances forming elsewhere in the family.
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2) De – Triangulation
Triangulation – A situation in which two family members involve a third family member in a conflictual
scenario. Bowen considers de-triangulation of self from the family emotional system.
Triangulation and Nuclear Family Emotional System. Bowen (1976) notes that anxiety can easily develop
within intimate relationships.
Under stressful situations, two people may recruit a third person into the relationship to reduce the anxiety
and gain stability. This is called triangulation.
When tension arises between two people and a third is engaged to relieve the tension it is called
triangulation . When tension is greater than what the three person system can handle, a series of
interlocking triangles is created. For example, three people create one triangle, four people
create four interlocking triangles and five people create nine interlocking triangles etc. Each
triangle has two positive sides and one negative side.
Bowen (1978) identifies two variables important in determining why triangles occur in
relationships. The first is the level of differentiation . This refers to the degree to which
individuality is maintained in a system. The second variable is the level of anxiety . This refers
to the amount of emotional tension in a system. A low level of differentiation, or a higher level
of anxiety produce more triangling.
Anticipating and diffusing triangulating maneuvers forces the parties to focus on the problem.
Other successful strategies in remaining de-triangled are seriousness and humor.
Although triangulation may lessen the emotional tension between the two people, the underlying conflict is
not addressed, and in the long run the situation worsens: What started as a conflict in the couple evolves into
a conflict within the nuclear family emotional system.
Family Projection Process and Multigenerational Transmission. The most common form of triangulation
occurs when two parents with poor differentiation fuse, leading to conflict, anxiety and ultimately the
involvement of a child in an attempt to regain stability. When a parent lacks differentiation and confidence
in her or his role with the child, the child also becomes fused and emotionally reactive.
The child is now declared to “have a problem,” and the other parent is often in the position of calming and
supporting the distraught parent. Such a triangle produces a kind of pseudo stability for a while: the
emotional instability in the couple seems to be diminished, but it has only been projected onto the child.
This family projection process makes the level of differentiation worse with each subsequent generation
(Papero, 2000). When a child leaves the family of origin with unresolved emotional attachments, whether
they are expressed in emotional fusion or emotional cutoff, they will tend to couple and create a family in
which these unresolved issues can be re-enacted. The family projection process has now become the
foundation for multigenerational transmission.
E.g.: when parents have unresolved and intense conflicts, they may focus on their offspring. Thus one or
more children may become problematic as a result of being triangulated into their parents’ relationship.
Instead of fighting with each other, the parents are temporarily distracted by riveting their attention on their
child(ren). Similarly, the conflict between the parents also may involve the triangulation of the child(ren) as
interpreters of one to the other.
Thomas Fogarty introduced to Bowen theory a distinction between triangles and triangulation. For him, the
former was a structure that existed in all families while the latter was an emotional process.
His focus on couples led him to believe that there was directional movement within family triangles that
almost always included a pursuer and a distancer.
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These were complementary relational positions whereby
- the pursuer is someone who wants lots of relational contact, especially during times of stress;
- the distancer is less expressive of thoughts and feelings, and often finds comfort in necessary tasks
rather than relationship.
3) Differentiation Of The Self and Emotional Cutoff.
The cornerstone of Bowen's theory is differentiation of the self, which involves both the psychological
separation of intellect and emotion and independence of the self from others.
Differentiated individuals are able to choose to be guided by their thoughts rather than their feelings.
Undifferentiated people have difficulty in separating themselves from others and tend to fuse with dominant
emotional patterns in the family.
- These people have a low degree of autonomy,
- They are emotionally reactive, and
- They are unable to take a clear position on issues:
Self-differentiation was Bowen’s principal goal of family therapy.
- they have a pseudo-self.
Bowen would model differentiation to his clients by using "I" statements and taking ownership of his own
thoughts, feelings, and behaviours. Differentiation – The ability of an individual to separate rational and
emotional selves.
Functional families are characterized by each member's success in finding the healthy balance between
belonging to a family and maintaining a separate identity.
One way to find the balance between family and individual identity is to define and clarify the boundaries
that exist between the subsystems. A family may have several subsystems such as a spouse, sibling, and
parent-child subsystem. Each subsystem contains its own subject matter that is private and should remain
within that subsystem.
Boundaries between subsystems range from rigid to diffuse. One of the most common family problems is a
weak boundary between subsystems
Diffuse boundaries can lead to over-enmeshment.
Enmeshment: inappropriate, boundary-violating closeness in which family members are emotionally
overreactive to one another
Rigid boundaries allow too little interaction between family members, which may result in disengagement.
(Disengagement: too much emotional distance between family members.)
Overall, human systems tend to work best when subsystem boundaries are clear (neither too open nor too
closed), interactions are clear and nonrepetitive, lines of authority are visible, rules are overt and flexible,
changing alignments replace rigid coalitions, and stressors are confronted instead of pushed onto scapegoats
Families who understand and respect differences between healthy and unhealthy subsystem boundaries and
rules function successfully. Families who do not understand and respect these differences find themselves in
a dysfunctional state of conflict.
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People who are fused to their families of origin tend to marry others to whom they can become fused;
that is, people at similar levels of differentiation tend to seek out and find each other when coupling.
One pseudo-self relies on another pseudo-self for emotional stability.
Unproductive family dynamics of the previous generation are transmitted from one generation to the next
through such a marriage (Becvar & Becvar, 2003).
In family systems theory, the key to being a healthy person encompasses both a sense of belonging to one's
family and a sense of separateness and individuality.
Differentiation from the family of origin allows one to accept personal responsibility for one’s thoughts,
feelings, perceptions, and actions.
Simply leaving one’s family of origin physically or emotionally, however, does not imply that one has
differentiated. Indeed, Bowen’s phrase for estrangement or disengagement is emotional cutoff, a strong
indication of an undifferentiated self.
Individuation, or psychological maturity, is a lifelong developmental process that is achieved relative to the
family of origin through re examination and resolution of conflicts within the individual and relational
contexts.
The distinction between emotional reactivity and rational thinking can be difficult to discern at times.
Those who are not emotionally reactive experience themselves as having a choice of possible responses;
their reactions are not automatic but involve a reasoned and balanced assessment of self and others.
Emotional reactivity, in contrast, is easily seen in clients who present themselves as paranoid, intensely
anxious, panic stricken, or even “head over heels in love.” In these cases, feelings have overwhelmed
thinking and reason, and people experience themselves as being unable to choose a different reaction.
Emotional reactivity in therapists almost always relates to unresolved issues with family-of-origin members.
For example, the sound of a male’s voice in a family session reminds the therapist of his father and
immediately triggers old feelings of anger and anxiety as well as an urgency to express them. Clarity of
response in Bowen’s theory is marked by a broad perspective, a focus on facts and knowledge, an
appreciation of complexity, and a recognition of feelings, rather than being dominated by them: Such people
achieve what Bowen sometimes referred to as a solid self (Becvar & Becvar, 2003).
4) Understanding family emotional systems.
Understanding family emotional systems and how they work is central to Bowen's theory.
The nuclear emotional process refers to how the family system operates in a crisis.
The family projection process refers to how parents pass good and bad things on to their children.
The multigenerational transmission process refers to how a family passes its good and baggage
between generations
Bowen focused on how family members could maintain a healthy balance between
- being enmeshed (overly involved in each other’s lives)
- and being disengaged (too much detachment from each other).
Although all family therapists are interested in resolving problems presented by a family and decreasing
symptoms, Bowen therapists are mainly interested in changing the individuals within the context of the
system.
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They contend that problems that are manifest in one's current family will not significantly change until
relationship patterns in one's family of origin are understood and addressed. Emotional problems will be
transmitted from one generation to the next 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.
Living systems and all the other system-related processes--move forward through key "horizontal"
transitional stages (brought about by time and change).
Symptoms occur when vertical stressors (old issues, past mistakes, emotional legacies) impinge on the
system during a transition.
Families are likeliest to be conflicted and symptomatic when key horizontal transitions like marriage, the
birth of children, children going to school, children moving away from home, changes of jobs, etc. coincide
with a resurfacing of vertical stressors like old emotional baggage.
Example: a workaholic husband driven to succeed by high internalized standards that equate esteem with
production (vertical stressor) puts in even more overtime to stuff the loneliness he feels when his eldest son
leaves for college (horizontal stressor).
In this case, part of the therapeutic agenda would include giving the family tools for negotiating the "empty
nest syndrome" while helping the husband get in touch with his mourning, examine his expectations of
himself, and reconnect with his family.
Calibration: setting of a present-oriented, systemwide range limit around a comfortable emotional "bias."
A typical situation: an unintense family with a cool emotional atmosphere unconsciously selects a member
to turn up the heat; brother and sister start fighting. This turns into an argument between the parents, the
drama escalates, and then, before it gets too hot, a child who plays the role of family ambassador calms
everybody down.
In that family the bias, the emotional level setting, is too low; a good dose of constructive intensity might
recalibrate the bias and make explosions unnecessary.
Self-regulating via feedback loops--negative (toward stability) and positive (toward change)--that maintain
the bias.
Every seasoned drug and alcohol counsellor knows that when one member of the family stops drinking or
using, the family will subtly try to push him back into his old vices--not because they want him sick, but
because families, like other organisms, naturally resist changes that might further destabilize the system.
So one day the husband says to his abstaining wife, "Why not skip your AA meeting tonight so we can
catch a movie?" Or the mother of a teen who's quit using congratulates him on finding a job--in a head shop.
Introducing positive (= system-changing) feedback loops into these families might include warning them
about enabling, relapses and resistance to change and examining what family members gain from having a
malfunctioning member (control? A scapegoat? Distraction from other conflicts? Someone to rescue?).
5) Sibling Position.
Bowen adopted Toman’s (1993) conceptualization of family constellation and sibling (or birth) position.
Toman believed that position determined power relationships, and gender experience determined one’s
ability to get along with the other sex.
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In addition to noting the unique positions of only children and twins, Toman focused on ten power/sex
positions:
1. the oldest brother of brothers;
2. the youngest brother of brothers;
3. the oldest brother of sisters;
4. the youngest brother of sisters;
5. the male only child;
6 – 10 and the same five configurations for females in relation to sisters and brothers.
Under this conceptualization, the best possible marriage, for example, is hypothesized to be the oldest
brother of sisters marrying the youngest sister of brothers; in this arrangement, both parties would enter the
marriage with similar expectations about power and gender relationships. Conversely, the worst marriage
would occur between the oldest brother of brothers and the oldest sister of sisters. In this case, both parties
would seek and want power positions, and neither would have had enough childhood experience with the
other sex to have adequate gender relationships.
Toman supported his hypothesis by noting that the divorce rate among couples comprised of two oldest
children was higher than any other set of birth positions. The absence of divorce, however, is not the same
as a happy marriage. When we consider the critical traits in a happy marriage, his predictions based on birth
order start to lose credibility. Happiness in coupling or marriage is demonstrably more related to attitudinal
and behavioural interactions within the spousal system—especially during periods of family stress—than to
birth order (Gottman, 1994, Walsh, 2003).
Guerin (2002) discussed the importance of what he called the “sibling cohesion factor” (p. 135), especially
when there were more than two children in the sibling subsystem, allowing for triangles to form. The
sibling cohesion factor is the capacity of the children within the sibling subsystem to meet without their
parents and discuss important family issues, including their evaluation of their parents. Healthier families
tend to have this factor as part of the family process; the lack of it suggests to Guerin that there is intense
triangulation between the parents and children.
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Normal Family Development
To Bowen, all families lie along a continuum. While you might try to classify families as falling into
discreet groups, there really are no "types" of families, and most families of one type could become a family
of another type if their circumstances changed. In many ways, Bowen was among the first of the culturally
sensitive family therapists.
Bowen believed that optimal family development occurs when family members are differentiated, feel little
anxiety regarding the family, and maintain a rewarding and healthy emotional contact with each other.
Fogarty offers that adjusted families
are balanced in terms of their togetherness and separateness, and can adapt to changes in the
environment
view emotional problems as coming largely from the greater system but as having some
components in the individual member
are connected across generations to extended family
have little emotional fusion and distance
have dyads that can deal with problems between them without pulling others into their difficulties
tolerate and support members who have different values and feelings, and thus can support
differentiation
are aware of influences from outside the family (such as Societal Emotional Processes) as well as
from within the family
allow each member to have their own emptiness and periods of pain, without rushing to resolve or
protect them from the pain and thus prohibit growth
preserve a positive emotional climate, and thus have members who believe the family is a good one
have members who use each other for feedback and support rather than for emotional crutches
Family Disorders
Bowen believed that family problems result from emotional fusion, or from an increase in the level of
anxiety in the family. Typically, the member with "the symptom" is the least differentiated member of the
family, and thus the one who has the least ability to resist the pull to become fused with another member, or
who has the least ability to separate their own thoughts and feelings from those of the larger family. The
member "absorbs" the anxiety and worries of the whole family and becomes the most debilitated by these
feelings. Families face two kinds of problems. Vertical problems are "passed down" from parent to child.
Thus, adults who had cold and distant relationships with their parents do not know how to have warm and
close relationships with their children, and so pass down their own problems to their children. Horizontal
problems are caused by environmental stressors or transition points in the family development. This may
result from traumas such as a chronic illness, the loss of the family home, or the death of a family member.
However, horizontal stress may also result from Social Emotional Processes, such as when a minority
family moves from a like-minority neighbourhood to a very different neighbourhood, or when a family with
traditional gender roles immigrates to a culture with very different views, and must raise their children
there. The worst case for the family is when vertical and horizontal problems happen at once.
Family Therapy with One Person
Family therapy can be done with one person. Such therapy typically focuses on differentiation of the person
from the family. The therapist helps the individual stop seeing family members in terms of the roles (parent,
sibling, caretaker...) they played, and start seeing them as people with their own needs, strengths, and flaws.
The individual learns to recognize triangulation, and take some ownership in allowing or halting it when it
happens. The individual client should have good insight into the family (genograms may be especially
helpful in this), and be very motivated to make changes either in his or her own life, or in the family.
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Goals of Therapy
The practice of Bowen family therapy is governed by the following two goals:
(1) lessening of anxiety and symptom relief and
(2) an increase in each family member's level of differentiation of the self (Kerr & Bowen, 1988).
To bring about significant change in a family system, it is necessary to open closed family ties and to
engage actively in a detriangulation process (Guerin, Fogarty, Fay, & Kautto, 1996). Although problems
are seen as residing in the system rather than in the individual, the route to changing oneself is through
changing in relationship to others in the family of origin.
Bowen encouraged his clients to come to know others in their family as they are.
He helped individuals or couples gather information, and he coached or guided them into new behaviours by
demonstrating ways in which individuals might change their relationships with their parents, siblings, and
extended family members.
He instructed them how to be better observers and also taught them how to move from emotional reactivity
to increased objectivity.
He did not tell clients what to do, but rather asked a series of questions that were designed to help them
figure out their own role in their family emotional process
Treatment entails
reframing the presenting problem as a multigenerational problem that is caused by factors beyond
the individual
lowering anxiety and the "emotional turmoil" that floods the family so they can reflect and act more
calmly
increasing differentiation, especially of the adult couple, so as to increase their ability to manage
their own anxiety, transition more effectively to parenthood, and thus fortify the entire family unit's
emotional wellbeing
using the therapist as part of a "healthy triangle" where the therapist teaches the couple to manage
their own anxiety, distance, and closeness in healthy ways
forming relationships with the family member with "the problem" to help them separate from the
family and resist unhealthy triangulation and emotional fusion
opening closed ties with cut off members
focusing on more than "the problem" and including the overall health and happiness of the family
evaluating progress of the family in terms of how they function now, as well as how adaptive they
can be to future changes
addressing the power differential in heterosexual couple based on differences, for example, in
economic power and gender role socialization (this is a contribution of those who have reconsidered
Bowen's theory through a feminist lens)
In general, the therapist accomplishes this by giving less attention to specific problem they present with, and
more attention to family patterns of emotions and relationships, as well as family structures of dyads and
triangles.
More specifically, the therapist
tries to lower anxiety (which breeds emotional fusion) to promote understanding, which is the
critical factor in change; open conflict is prohibited as it raises the family members' anxiety during
future sessions
remains neutral and detriangulated, and in effect models for the parents some of what they must do
for the family
promotes differentiation of members, as often a single member can spur changes in the larger
family; using "I" statements is one way to help family members separate their own emotions and
thoughts from those of the rest of the family
develops a personal relationships with each member of the family and encourages family members
to form stronger relationships too
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encourages cut off members to return to the family
may use descriptive labels like "pursuer-distancer," and help members see the dynamic occurring;
following distancers only causes them to run further away, while working with the pursuer to create
a safe place in the relationship invites the distancer back.
coaches and consults with the family, interrupts arguments, and models skills...
Techniques
Bowen did not believe in a "therapeutic bag of tricks." Questioning the family and constructing a family
genogram are the closest things to basic techniques all Bowenian therapists would use. Carter has assigned
tasks to the adult couple to help them realize more about their family history, and encourages letter writing
to distant members, visiting mother-in-laws... to speed things up. Guerin accepts the family's opinion of who
"has the problem" and works from there with a variety of techniques to help all family members own some
responsibility for helping that sick member get better. He will also use stories or films to present another
real or imaginary family with the same problem as the family in therapy, and highlight how the family in the
story or film overcame their difficulties.
Other concepts:
Emotional divorce (like when a sick child holds the parents together); theory is important; no one ever really
leaves the family system; mother-child symbiosis when unresolved predisposes to schizophrenia; solid self
vs. pseudo self; over- under adequate reciprocity.
Two natural forces: growth of individual and emotional connection. Emphasized the first.
Fusion breeds anxiety and increases emotional reactivity. Three outcomes of fusion: physical or mental
dysfunction in a spouse; in a child; chronic marital conflict.
Dysfunctional reciprocal relationships: include over adequate/under adequate, decisive/indecisive,
dominant/submissive, hysterical/obsessive, schizoid/conflict, or cut-off between spouses.
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MORE ABOUT TRIANGLES
1. Cross-generational coalitions
Cross-generational coalitions (i.e. mother-father-child triangles) are associated with child behaviour
problems.
In studies of adolescent antisocial behaviour, differences in dyadic interaction between families with a child
with behaviour problems and families with a well adjusted child have been evaluated.
Empirical studies show that on average:
Children with behaviour problems are more aligned with their mothers and more disengaged from their
fathers than are the well-adjusted adolescents.
Parents of children with behaviour problems have more discordant relations than the parents of welladjusted
adolescents.
Within families of well-adjusted adolescents, the parents are more supportive of each other than the
adolescent.
This suggests that strengthening the parental dyad through the resolution of marital problems, and
promoting more positive father-adolescent relations will weaken the cross-generational coalition and
ameliorate the symptomatic behaviour.
In another study , the family triangle was defined as a family systems construct used to describe family
communication patterns in which a dyad cannot cope with demands for intimacy or conflict resolution. As
such, triangles occur to reduce tension between two people, but are problematic because they do not provide
solutions.
2. The authors reviewed three family triangles:
Triangulation: occurs when a parent demands that a child side with her or him against the other parent.
Detouring: occurs when spouses ignore the issues in their own relationship and focus on the child's
issues.
Cross-generational coalition: exists when one parent sides with a child against another parent.
This differs from triangulation because it is the parent who initiates the coalition and the attachment
between the parent and the child exceeds that between the parents.
All three family triangles are considered to have negative developmental effects on the child.
They create a false sense of attachment and security and do not give the child the opportunity to
develop a healthy separate identity. For this reason the study considers the "impact of crossgenerational
coalitions on interpersonal intimacy and view intimacy as a developmental task relevant to
young adults"
Children with a cross-generational attachment have larger intellectual-intimacy, emotional-intimacy
and sexual-intimacy discrepancy scores.
Cross-generational coalitions also affect the ability to successfully negotiate psycho-social
developmental tasks. Tests reveal that, even while away from home, children are still affected by the
family triangle.
"Detriangulating" can contribute considerably in resolving intimacy issues. Detriangulating involves:
a) not talking with one parent about the other parent,
b) teaching the client about triangulation patterns,
c) the client becoming more objective and less emotional with his or her parents.
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Because the family is not a static entity, a change in one part of the system affects the actions of all others
involved. Bowen sometimes worked with one member of a conflictual dyad (or couple). He did not require
that every family member be involved in the therapy sessions.
Bowen tended to work from the inside out: Starting with the spousal relationship, he helped the two adults
establish their own differentiation.
As a therapist, he attempted to maintain a stance of neutrality. If the therapist becomes emotionally
entangled with any one family member, the therapist loses effectiveness and becomes part of a triangulated
relationship.
Bowen maintains that, to be effective, family therapists have to have a very high level of differentiation. If
therapists still have unresolved family issues and are emotionally reactive, they are likely to revisit those
difficulties in every family they see.
3. Vogel, E.F. and Bell, N.W. (1968). The Emotionally Disturbed Child as the Family Scapegoat.
The purpose of this study was to learn more about how "the emotionally disturbed child used as a scapegoat
for the conflicts between parents and what the functions and dysfunctions of this scapegoating are for the
family." (p. 412)
When parents experience crises for which they have no adequate coping mechanisms, they look for ways to
discharge some of the tension. One of the most common methods is to involve a third person. When the
third person is their child, parents often project their problems on to the child. They focus their attentions on
the problems of the child so they can avoid the pain of admitting their own problems. This is what Vogel
and Bell call "scapegoating".
There were many reasons why the child was selected as the scapegoat.
First, the child was relatively powerless to leave the family nor to counter the parents triangulation. The
child's personality is very flexible and adopts quickly to the assigned role of scapegoat.
The child has few task which are vital in the maintenance of the family. "The cost in dysfunction of the
child is low relative to the functional gains for the whole family."
Often, the chosen child would best symbolize the parental conflicts. For example, if the conflict was
over achievement, the child who stood out most (for either over- or under-achieving) would be targeted.
Children were also picked because they possessed the same undesirable traits (either physically,
behaviourally or emotionally) as the parent.
The study also found that the scapegoated child had a (considerably) lower IQ than the other children.
Many had physical abnormalities.
All of the parents reported having had tensions since early in the marriage.
Once the child is selected she or he must carry out the role of the problem child. The authors found that the
problem behaviour was reinforced through inconsistent parenting.
The dysfunction would be both supported and criticized. In some cases, parents would encourage opposing
types of behaviour. In other instances parents promoted different norms. This set up a self-perpetuating
cycle which "normalized" the child's problems. The dysfunction became part of the family.
The families used rationalizations to maintain the equilibrium attained when the child took on the parents'
problems.
One rationalization was that the parents, rather than the children, were the victims.
Another was to emphasize how fortunate the child was, because their life was better than the parents.
The parents felt justified in depriving the children of things they wanted and then used the complaints
to reinforce the scapegoating.
Another common belief was that the child could behave if she or he wanted to. This rationalized sever
punishment.
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The authors point out that there are both functions and dysfunctions of scapegoating.
For the parents, scapegoating serves to stabilize their relationship. They were also better able to live up
to the societal expectations of a happy marriage. Scapegoating permits the family to maintain its
solidarity. At the same time, communities can scapegoat the family with the dysfunctional child.
One of the dysfunctions is that scapegoating creates "realistic problems and extra tasks" for the family.
Another is that the child often becomes very adept at fighting back and usually directs their aggression
towards the ever-present mother.
4. Marks, S. (1989). Towards a systems theory of marital quality.
Marks (1989) suggests that relationships can be understood in terms of two intersecting triangles. He has
borrowed Margaret Mead's concept of "I" and "me" in describing the nature of the triangle. The "I" is the
presentation of the self at that moment or in that situation. This contrasts with the "me" which is an
organization of tendencies. The situation brings the "I" out of the "me". The triangle is three points and
those can be understood as three tendencies, or three "me" corners. At any given moment one corner will be
the focus of energy. That corner will then be the "I", the present manifestation of the tendencies. In therapy,
the placement of the "I" structures the future.
Each triangle has three corners.
1) The first corner is the Inner-self (I-corner), the driving force.
2) The second is the Partnership (P-corner) corner. This coordinates the self with a primary partner.
3) The third corner is any area where the self concentrates energy that is different from the first two
corners, e.g. job, children, religion, friends etc.
Marks' conception differs from Bowen's view of triangles in marriage. Bowen sees the couple as two
corners of the triangle. The couple uses the third corner as a buffer against their tension. The third corner
provides a distraction and relieves the marital pressure. In a marital therapy situation, the therapist can act as
the third corner.
The "Three Corners" model is a systems theory of the self in marriage. A traditional concept in marriage
therapy is "marital quality". Marks states "Quality of marriage is a consequence of the way married selves
are systematically organized. A person whose "I" maintains some regular motion around and between all
three corners has a high quality marriage."
The article introduces seven different manifestations of the dual triangle construct.
The first three are low quality relationships. These are characterized by a concentration of energy on one
corner without a flow of energy to all parts.
1) The first triangle is the "Romantic Fusion", wherein all the energy is focused on the P . This is the
traditional beginnings of a relationship. This becomes unhealthy after a while because other areas of the
self are neglected.
2) The second is the "Dependency-Distancing" relationship. This is a traditional unhealthy female-male
situation where the woman places energy on the partner and the partner (the man) places energy on the
3rd corner, usually work.
3) The third is the "Separated" relationship where both people focus their energy on their 3rd corner.
Marks says that while this can be very healthy and stable, as a marriage is concerned it is low quality.
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The last four triangles represent high quality marriages.
There is a radical shift in the conception of the triangle. Because there is a constant flow of energy, the three
points are connected by rounded lines, making a circle. This represents uninterrupted energy flow between
the "me's". In a high quality marriage there is a multiplicity of healthy connections which are as dynamic
and fluid as the energy.
4) The fourth is the "Balanced Connection" which has an equal concentration of energy.
5) The fifth is "Couple Centered". The energy is focused on the P , but differs from the second triangle in
that the other "me's" receive energy.
6) The sixth is "Family Centered". Both people focus their energy on the family, which would be a joint
3rd interest.
7) The seventh is "Loose". The energy is focused on the 3rd , without detriment to the stability of the
couple because, again, there is a steady flow of energy to the other corners.
Marks' (1989) concept of the self as a triangle is very useful and deserves more attention. A useful
application would be in Slater's (1994) article on triangles in committed lesbian relationships. In his article,
Marks does not discuss the possibility of energy revolving around the "I". This might reflect an assumption
that there is a sufficient concentration on the "I" naturally, that the inner-self is the base of all the external
interactions. This assumes a degree of differentiation that, developmentally, is traditionally more male than
female. Slater points out that the affected partner needs consolidate her sense of identity and perceive it as
originating within herself. This would result in the "I" in Marks' model to be the focus of energy. Without
this option, the therapist would concentrate the affected partner on the "P" and miss the opportunity for
individual growth.
Criticisms on the triangle theory
As exciting and varied as triangle theory is, there are valid criticisms. One is that the majority of the studies
focused on dependence as being the dominant catalyst for problems. A good example is West (1986) who
states : “In this enmeshed situation the child seems to experience a distorted sense of attachment,
involvement, or belonging with the family and fails to experience a secure sense of separateness,
individuality or autonomy. “
This implies that independence is more important than attachment, and given what we know about gender
roles, that male characteristics are more important than female characteristics. The possible gender bias
could be addressed by a study on the role of an overly-detached family member on the creation of triangles.
This would look at the role that stereotypical male behaviour has on the other two members.
133

Salvador Minuchin’s Structural Family
Therapy
From Wikipedia, the free encyclopedia
And http://www.allpsychologycareers.com/topics/family-systems-therapy.html
AllPsychologyCareers.com - © 2008-2013 AllPsychologyCareers.com. All Rights Reserved.
This site is for informational purposes and is not a substitute for professional help.
Structural Family Therapy (SFT) is a method of psychotherapy developed by Salvador Minuchin which
addresses problems in functioning within a family. Structural Family Therapists strive to enter, or "join", the
family system in therapy in order to understand the invisible rules which govern its functioning, map the
relationships between family members or between subsets of the family, and ultimately disrupt
dysfunctional relationships within the family, causing it to stabilize into healthier patterns. Minuchin
contends that pathology rests not in the individual, but within the family system.
SFT utilizes, not only a unique systems terminology, but also a means of depicting key family parameters
diagrammatically. Its focus is on the structure of the family, including its various substructures. In this
regard, Minuchin is a follower of systems and communication theory, since his structures are defined by
transactions among interrelated systems within the family. He subscribes to the systems notions of
wholeness and equifinality, both of which are critical to his notion of change. An essential trait of SFT is
that the therapist actually enters, or "joins", with the family system as a catalyst for positive change. Joining
with a family is a goal of the therapist early on in his or her therapeutic relationship with the family.
Family Rules
Contents
1 Family Rules
2 Therapeutic Goals and Techniques
3 See also
4 References
Consider the human body’s complexity and how a change in one physiological component alters and
impacts so many other parts. The interrelation and interdependence of parts are integrally related so that the
body’s ability to function at all depends on an intricate web of connectedness.
Now consider a family, perhaps a mother, father, and child (or children), and think of them as one human
body – an organism, or a whole. One component of the family, or one individual, simply cannot be
separated or understood in isolation. One individual affects all others; everyone’s deeply embedded
emotional and behavioral processes seamlessly wired together.
Family systems professionals and therapists describe the family as a complex and interconnected system.
Maladaptive behaviors are connected, and therefore likely to affect and create “dis-ease” in other areas – if
not appropriately treated. When a change occurs in one part of the system, such as a mental health or
behavioral issue, therapists must treat the entire family to help the individual regain healthy functioning.
Additionally, the entire system or family can become plagued with maladaptive interactions so that it seems
to literally stop functioning.
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Assumptions of family systems
A Juvenile Justice Bulletin published by the U.S. Department of Justice, Office of Juvenile Justice and
Delinquency Prevention, summarized the main aspects of family systems therapy as follows:
A family is a system composed of interdependent and interrelated parts.
The behavior of one family member is only understood by examining the context (i.e., family) in
which it occurs.
Interventions must be implemented at the family level and must take into account the complex
relationships within the family system.
Includes all types of families :
During the 1950s and 1960s, family systems therapy began with a focus on the traditional family unit, but
has expanded to include therapy for all types of familial relationships, including gay and lesbian couples and
families, extended families related through divorce and re-marriage, and other family units that don’t
necessarily include a biological mother and father.
Whatever the composition of individual members, a group that calls itself a family, and lives like a family,
can be treated by family systems therapists.
In SFT, family rules are defined as an invisible set of functional demands that persistently organizes the
interaction of the family. Important rules for a therapist to study include coalitions, boundaries, and power
hierarchies between subsystems.
According to Minuchin, a family is functional or dysfunctional based upon its ability to adapt to various
stressors (extra-familial, idiosyncratic, developmental), which, in turn, rests upon the clarity and
appropriateness of its subsystem boundaries. Boundaries are characterized along a continuum from
enmeshment through semi-diffuse permeability to rigidity. Additionally, family subsystems are
characterized by a hierarchy of power, typically with the parental subsystem "on top" vis-à-vis the offspring
subsystem.
In healthy families, parent-children boundaries are both clear and semi-diffuse, allowing the parents to
interact together with some degree of authority in negotiating between themselves the methods and goals of
parenting. From the children’s side, the parents are not enmeshed with the children, allowing for the degree
of autonomous sibling and peer interactions that produce socialization, yet not so disengaged, rigid, or aloof,
ignoring childhood needs for support, nurturance, and guidance. Dysfunctional families exhibit mixed
subsystems (i.e., coalitions) and improper power hierarchies, as in the example of an older child being
brought in to the parental subsystem to replace a physically or emotionally absent spouse.
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The family – homeostasis & change
The family is conceptualized as a living open system. In every system the parts are functionally
interdependent in ways dictated by the supra-individual functions of the whole. In a system AB, A’s
passivity is read as a response to B’s initiative (interdependence), while the pattern passivity! initiative is
one of the ways in which the system carries on its function (for example, the provision of a nurturing
environment for A and B). The set of rules regulating the interactions among members of the system is its
structure.
As an open system the family is subjected to and impinges on the surrounding environment. This implies
that family members are not the only architects of their family shape; relevant rules may be imposed by the
immediate group of reference or by the culture in the broader sense. When we recognize that Mr. Brown’s
distant relationship to Jimmy is related to Mrs. Brown’s over-involvement with Jimmy, we are witnessing
an idiosyncratic family arrangement but also the regulating effects of a society that encourages mothers to
be closer to children and fathers to keep more distance.
Finally, as a living system the family is in constant transformation: transactional rules evolve over time as
each family group negotiates the particular arrangements that are more economical and effective for any
given period in its life as a system. This evolution, as any other, is regulated by the interplay of homeostasis
and change.
Homeostasis designates the patterns of transactions that assure the stability of the system, the maintenance
of its basic characteristics as they can be described at a certain point in time; homeostatic processes tend to
keep the status quo (Jackson, 1957, 1965). The two-way process that links A’s passivity to B’s initiative
serves a homeostatic purpose for the system AB, as do father’s distance, mother’s proximity and Jimmy’s
eventual symptomatology for the Browns. When viewed from the perspective of homeostasis, individual
behaviors interlock like the pieces in a puzzle, a quality that is usually referred to as complementarity.
Change, on the other hand, is the reaccommodation that the living system undergoes in order to adjust to a
different set of environmental circumstances or to an intrinsic developmental need. A’s passivity and B’s
initiative may be effectively complementary for a given period in the life of AB, but a change to a different
complementarity will be in order if B becomes incapacitated. Jimmy and his parents may need to change if a
second child is born. Marriage, births, entrance to school, the onset of adolescence, going to college or to a
job are examples of developmental milestones in the life of most families; loss of a job, a sudden death, a
promotion, a move to a different city, a divorce, a pregnant adolescent are special events that affect the
journey of some families. Whether universal or idiosyncratic, these impacts call for changes in patterns, and
in some cases—for example when children are added to a couple— dramatically increase the complexity of
the system by introducing differentiation. The spouse subsystem coexists with parent-child subsystems and
eventually a sibling subsystem, and rules need to be developed to define who participates with whom and in
what kind of situations, and who are excluded from those situations. Such definitions are called boundaries;
they may prescribe, for instance, that children should not participate in adults’ arguments, or that the oldest
son has the privilege of spending certain moments alone with his father, or that the adolescent daughter has
more rights to privacy than her younger siblings.
In the last analysis homeostasis and change are matters of perspective. If one follows the family process
over a brief period of time, chances are that one will witness the homeostatic mechanisms at work and the
system in relative equilibrium; moments of crisis in which the status quo is questioned and rules are
challenged are a relative exception in the life of a system, and when crises become the rule, they may be
playing a role in the maintenance of homeostasis. Now if one steps back so as to visualize a more extended
period, the evolvement of different successive system configurations becomes apparent and the process of
change comes to the foreground. But by moving further back and encompassing the entire life cycle of a
system, one discovers homeostasis again: the series of smooth transitions and sudden recommendations of
which change is made presents itself as a constant attempt to maintain equilibrium or to recover it. Like the
donkey that progresses as it reaches for the carrot that will always be out of reach, like the monkeys that
turned into humans by struggling to survive as monkeys, like the aristocrats in Lampeduza’s Il Gatorade
who wanted to change everything so that nothing would change, families fall for the bait that is the paradox
of evolution: they need to accommodate in order to remain the same, and accommodation moves them into
something different.
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This ongoing process can be arrested. The family can fail to respond to a new demand from the environment
or from its own development: it will not substitute new rules of transactions for the ones that have been
patterning its functioning. AB find it impossible to let go of the passivity/initiative pattern even if B is now
incapacitated Jimmy and mother find it impossible to let go of a tight relationship that was developmentally
appropriate when Jimmy was 2 but not now that he is 18. Maybe Jimmy started showing trouble in school
when he was 12, but the family insisted on the same structure with mother monitoring all communications
around Jimmy and the school, so that Jimmy was protected from father’s anger and father from his own
disappointment.
When families get stagnated in their development their transactional patterns become stereotyped.
Homeostatic mechanisms exacerbate as the system holds tightly to a rigid script. Any movement threatening
a departure from the status quo is swiftly corrected. If father grows tougher on Jimmy, mother will intercede
and father will withdraw. Intergenerational coalitions that subvert natural hierarchies (for example, mother
and son against father), triangular patterns where parents use a child as a battleground, and other
dysfunctional arrangements serve the purpose of avoiding the onset of open conflict within the system.
Conflict avoidance, then, guarantees a certain sense of equilibrium but at the same time prevents growth and
differentiation, which are the offspring of conflict resolution. The higher levels of conflict avoidance are
found in enmeshed families— where the extreme sense of closeness, belonging, and loyalty minimize the
chances of disagreement—and, at the other end of the continuum, in disengaged families, where the same
effect is produced by excessive distance and a false sense of independence.
In their efforts to keep a precarious balance, family members stick to myths that are very narrow definitions
of themselves as a whole and as individuals— constructed realities made by the interlocking of limited
facets of the respective selves, which leave most of the system’s potentials unused. When these families
come to therapy they typically present themselves as a poor version of what they really are.
In the figure at the right side, the white area in the center
of the figure represents the myth: “I am this way and can
only be this way, and the same is true for him and for her,
and we can not relate in any other way than our way,”
while the shaded area contains the available but as yet not
utilized alternatives.
The presenting problem
Structural family therapy conceptualizes the problem
behavior as a partial aspect of the family structure of
transactions. The complaint, for instance, that Jimmy is
undisciplined and aggressive, needs to be put in
perspective by relating it to the context of Jimmy’s
family.
For one thing, the therapist has to find out the position and function of the problem behavior: When does
Jimmy turn aggressive? What happens• immediately before? How do others react to his misbehavior? Is
Jimmy more undisciplined toward mother than toward father? Do father and mother agree on bow to handle
him? What is the homeostatic benefit from the sequential patterns in which the problem behavior is
imbedded? The individual problem is seen as a complement of other behaviors, a part of the status quo, a
token of the system’s dysfunction; in short, the system as it is supports the symptom.
The therapist also has to diagnose the structure of the system’s perceptions in connection with the
presenting problem. Who is more concerned about Jimmy’s lack of discipline? Does everybody concur that
be is aggressive? That his behavior is the most troublesome problem in the family? Which are the other,
more positive facets in Jimmy’s self that go unnoticed? Is the family exaggerating in labeling as
“aggressive” a child that maybe is just more exuberant than his siblings? Is the family failing to
accommodate their perceptions and expectations to the fact that Jimmy is now 18 years old? Does the system
draw a homeostatic gain from perceiving Jimmy primarily as a symptomatic child? An axiom of
structural family therapy, illustrated by Figure 1, is that a vast area of Jimmy’s self is out of sight for both
his relatives and himself, and that there is a systemic support for this blindness.
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So the interaccional network knitted around the motive of complaint is the real “presenting problem” for the
structural family therapist. The key element in this view is the concept of systemic support. The model does
not claim a direct causal line between system and problem behavior; the emphasis is on maintenance rather
than on causation. Certainly, sometimes one observes families and listens to their stories and can almost see
the pathways leading from transactional structure to symptomatology. But even in these cases the model
warns us that we are dealing with current transactions and current memories, as they are organized now,
after the problem has crystallized. Thus, instead of a simplistic, one-way causal connection the model
postulates an ongoing process of mutual accommodation between the system’s rules and the individual’s
predispositions and vulnerabilities. Maybe Jimmy was born with a “strong temperament” and to a system
that needed to pay special attention to his temper tantrums, to highlight his negative facets while ignoring
the positive ones. Within this context Jimmy learned about his identity and about the benefits of being
perceived as an aggressive child. By the time he was 9, Jimmy was an expert participant in a mutually
escalating game of defiance and punishment. These mechanisms —selective attention, deviance
amplification, labeling, counter escalation— are some of the ways in which a system may contribute to the
etiology of a “problem.” Jimmy’s cousin Fred was born at about the same time and with the same “strong
temperament,” but he is now a class leader and a junior tennis champ.
Discussions around etiological history, in any case, are largely academic from the~ perspective of structural
family therapy, whose interest is focused on the current supportive relation between system and problem
behavior. The model shares with other systemic approaches the radical idea that knowledge of the origins of
a problem is largely irrelevant for the process of therapeutic change (Minuchin & Fishman, 1979). The
identification of etiological sequences may be helpful in preventing problems from happening to families,
but once they have happened and are eventually brought to therapy, history has already occurred and can
not be undone. An elaborate understanding of the problem history may in fact hinder the therapist’s
operation by encouraging an excessive focus on what appears as not modifiable.
The Process of Therapeutic Change
Consistent with its basic tenet that the problems brought to therapy are ultimately dysfunctions of the family
structure, the model looks for a therapeutic solution in the modification of such structure. This usually
requires changes in the relative positions of family members: more proximity may be necessary between
husband and wife, more distance between mother and son. Hierarchical relations and coalitions are
frequently in need of a redefinition. New alternative rules for transacting must be explored: mother, for
instance, may be required to abstain from intervening automatically whenever an interaction between her
husband and her son reaches a certain pitch, while father and son should not automatically abort an
argument just because it upsets Morn. Frozen conflicts have to be acknowledged and dealt with so that they
can be solved —and the natural road to growth reopened.
Therapeutic change is then the process of helping the family to outgrow its stereotyped patterns of which the
presenting problem is a part. This process transpires within a special context, the therapeutic system which
offers a unique chance to challenge the rules of the family. The privileged position of the therapist allows
him to request from the family members different behaviors and to invite different perceptions, thus altering
their interaction and perspective. The family then has an opportunity to experience transactional patterns
that have not been allowed under its prevailing homeostatic rules.
The system’s limits are probed and pushed, its narrow self-definitions are questioned; in the process, the
family’s capacity to tolerate and handle stress or conflict increases, and its perceived reality becomes richer,
more complex.
In looking for materials to build this expansion of the family’s reality -alternative behaviors, attitudes,
perceptions, affinities, expectations- the structural family therapist has one primary source from which to
draw: the family itself. The model contends that beyond the systemic constraints that keep the family
functioning at an inadequate level there exists an as yet underutilized pool of potential resources. Releasing
these resources so that the system can change, and changing the system so that the resources can be
released, are simultaneous processes that require the restructuring input of the therapist. His role will be
discussed at some length in the following section.
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Therapeutic Goals and Techniques
Minuchin’s goal is to promote a restructuring of the family system along more healthy lines, which he does
by entering the various family subsystems, "continually causing upheavals by intervening in ways that will
produce unstable situations which require change and the restructuring of family organization... Therapeutic
change cannot occur unless some pre-existing frames of reference are modified, flexibility introduced and
new ways of functioning developed." To accelerate such change, Minuchin manipulates the format of the
therapy sessions, structuring desired subsystems by isolating them from the remainder of the family, either
by the use of space and positioning (seating) within the room, or by having non-members of the desired
substructure leave the room (but stay involved by viewing from behind a one-way mirror). The aim of such
interventions is often to cause the unbalancing of the family system, in order to help them to see the
dysfunctional patterns and remain open to restructuring. He believes that change must be gradual and taken
in digestible steps for it to be useful and lasting. Because structures tend to self-perpetuate, especially when
there is positive feedback, Minuchin asserts that therapeutic change is likely to be maintained beyond the
limits of the therapy session.
One variant or extension of his methodology can be said to move from manipulation of experience toward
fostering understanding. When working with families who are not introspective and are oriented toward
concrete thinking, Minuchin will use the subsystem isolation—one-way mirror technique to teach those
family members on the viewing side of the mirror to move from being an enmeshed participant to being an
evaluation observer. He does this by joining them in the viewing room and pointing out the patterns of
transaction occurring on the other side of the mirror. While Minuchin doesn’t formally integrate this
extension into his view of therapeutic change, it seems that he is requiring a minimal level of insight or
understanding for his subsystem restructuring efforts to "take" and to allow for the resultant positive
feedback among the subsystems to induce stability and resistance to change.
Change, then, occurs in the subsystem level and is the result of manipulations by the therapist of the existing
subsystems, and is maintained by its greater functionality and resulting changed frames of reference and
positive feedback.
See also
Family systems therapy
Salvador Minuchin
Systems theory
References
1. Minuchin, S. (1974). Families and Family Therapy. Harvard University Press.
2. Seligman, Linda (2004). Diagnosis and Treatment Planning in Counseling. New York: Kluwer
Academic. ISBN 0306485141., p. 246
Minuchin, S. & Fishman, H. C. (2004). Family Therapy Techniques. Harvard University Press.
Piercy, Fred (1986). Family Therapy Sourcebook. New York: Guilford Press. ISBN 0898629136.
Will, David (1985). Integrated Family Therapy. London: Tavistock. ISBN 042279760X.
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Definitions
Structure, subsystems and boundaries
The theoretical base of structural family therapy is the three constructs of structure, subsystems and
boundaries. As is the nature of constructs, they are noted through the presence of persistent, observable
patterns, interactions and relational styles in a family.
Family Structure – “organized pattern in which family members interact” - Reflects the division of tasks
among the various subsystems and the way units are coordinated within. Established patterns make way for
expectations and limitations in expressed behaviors in various given situations
The beginnings of the idea of changing the structure to alleviate symptoms lie here.
Subsystems – divisions or subgroups based on factors such as age, spousal relation, generation, etc…
Interactions, patterns and divisions of subsystems are often a little difficult to find amidst initial chaos
brought to therapy by the family.
Boundaries – “invisible barriers that regulate contact with others” - Range of boundaries: diffuse rigid -
Also affects dependence on outside systems and level of interpersonal engagement within the subsystem
Rigid Boundary : Disengagement - disengaged subsystem – independent yet isolated
Clear Boundary : Normal Range - subsystem with a clear boundary – a balance of independence
and dependence, and outside contact and isolation.
Diffuse Boundary : Enmeshment - enmeshed subsystem – lacks independent competence but offers
closeness and support
Examples demonstrating boundaries and subsystems
Minuchin used the example of a spousal subsystem to demonstrate the need for distinct boundaries
A spousal relationship demonstrates complementarity between members of a subsystem and patterns of
accommodation. Boundary defined by functions not shared with other subsystems, such as lovemaking.
Such a boundary also helps define a hierarchical structure within the family, with parents as heads of the
home.
Minuchin also made clear the consideration of ecology outside the family as a contributor to family
problems.
Normal Family Development: “What distinguishes a normal family isn’t the absence of problems but a
functional structure for dealing with them.”
Assumedly, the spousal subsystem is mentioned first since that is more or less the starting point of a nuclear
family. As hinted at before, accommodation leads to the prevalent patterns of the spousal subsystem and
eventual formation of family hierarchy, upon development of parent-child boundary.
Boundaries also form between new family and outside systems, including families of origin.
Minuchin notices that “growing pains” are part of adjustment to an expanding family and are not a sign of
pathology.
Development of behaviour disorders
Shifts in the family structure should be done in response to the introduction of external stressors, as
experienced by one or more of the family members
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Reaction to change:
Healthy families
Healthy families accommodate to changed circumstances
Both enmeshed and disengaged families express fear of change through conflict avoidance.
- Disengaged families accomplish this by avoiding contact
- Enmeshed families squabble, or deny their personal differences.
One special case where structural change is inherently part of family difficulty is in the formation of
“blended families”. Remarriage of divorcee or widower parents is both the introduction of an external
stressor and the restructuring of the family.
Example: rigid boundary forming between stepparent and biological parent/child (enmeshed) subsystem
Disengaged families
Disengaged families increase the rigidity of structures that are no longer functional
In disengaged families, preoccupation with other matters rather than current, pressing needs is
commonplace - Lack of awareness due to preoccupation
Enmeshed families
In enmeshed families, boundaries are diffuse and members become overly dependent on one
another
Example – intrusive parents hindering the development of their own children
Excessive involvement in minor conflicts, not allowing their young to solve their own problems.
It is difficult to categorize a subsystem as either disengaged or enmeshed, as the two concepts can be
reciprocal. One person in a relationship can be disengaged and the other enmeshed, as can happen in a
spousal subsystem.
“enmeshed mother/disengaged father syndrome,” a concept facing criticism
As with boundaries, hierarchies can be either be too rigid or too weak
Lack of control or guidance, excessive power struggles and other deficits in family stability are possible
Salvador Minuchin’s Style
Salvador Minuchin’s Structural Family Therapy is a directive therapy, change-oriented through changing
the family structure (transaction-governing rules of a family). A symptom services and is rooted in
dysfunctional transactions, structure (boundaries).
Salvador Minuchin’s style was to get the family to talk briefly until he identified a central theme of
concern and the leading and supporting roles in the theme.
Next he examined boundaries or family rules that define the participants, the areas of responsibility,
the decision making and privacy rules.
The idea is to change the immediate context of the family situation and thereby change the family
members’ positions.
His approach was both active and directive. He would shift the family focus from the identified
client to the therapist to allow the identified client to rejoin the family.
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When treatment is complete, the therapist moves outside the family structure and leaves the family
intact and connected without the loss of individual family member identities.
Family member behaviour can be understood only in the family context.
The Structural Family Therapy is a type of family therapy, based on the assumption that family member
behaviour is ongoing and repetitive and can be understood only in the family context.
This therapy may be characterized by the highly active therapist who gives specific directives for behaviour
change that are carried out as homework assignments.
Paradoxical interventions are often used to harness the strong resistance clients have to change and to taking
directives.
Clients may be asked to intensify the problem as one way of using paradox.
Another way is for the therapists to take a "one-down" position, encouraging the client not to do too much
too soon.
Counselors must differentiate between first-order and second-order changes.
First-order changes are those that help the system stay at its current level of functioning. They occur when
the symptom is temporarily removed, only to reappear later because the family system has not been
changed.
Second-order changes restructure the system to bring it to a different level. They occur when symptom and
system are repaired and the need for the symptom does not reappear.
E.g.: Teaching family members how to use "I" statements and listen empathically demonstrate first-order
changes that enhance the family's current functioning. Coaching a widow through the loss of her husband,
helping a couple let go of the last child to leave the nest, and restructuring an alcoholic family to eliminate
drinking are second-order changes that alter the family fundamentally, bringing it to an entirely new
structure and psychological place.
Key concepts:
Enmeshment: encourages somatisation, and disengagement, acting out. High resonance.
Ecological context: the family's church, schools, work, extended family members.
Sick child: family conflict defuser.
Common boundary problem: parents confuse spouse functions with parent functions.
Rules: generic and idiosyncratic rules that regulate transactions govern structure.
Boundaries: can be diffuse (enmeshed), rigid (disengaged), or clear.
Power: determined by authority and responsibility for acting on it.
Coalitions: can be stable or detouring.
Transitional anxieties: Families are constantly in transition, and transitional anxieties and lack of
differentiation are sometimes mislabelled pathological.
Reaction to therapist probes: A family will either dismiss the therapist's probes, assimilate to
previous transaction patterns, or respond as to a novel situation, in
which case stress increases and the probe is restructuring.
Rigid triad: where parents habitually use a child to lightning rod conflict.
Rigid boundary around the triad; common when the children have
severe psychosomatic problems.
Dysfunctional families: A dysfunctional family is one that responds to inner or outer demands
for change by stereotyping its functioning.
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Three reasons that make clients move:
They are challenged in their perception of their reality, given alternative possibilities that make sense, or
self-reinforcing new relationships appear once they've tried out new alternatives. People need some support
within a family to move into the unknown.
Conditions for behaviour change
Much like the formation of a new family, the joining of a therapist into the family system involves
accommodating to the current family members.
Accommodation allows for restructuring to occur, with a minimized risk of rejection by the family.
The opposite is a possible danger as well, with a therapist becoming too close of a family member, with his
changes being assimilated into current maladaptive patterns with no change.
Family members must be assured of the acceptance and respect of their lifestyle by the therapist, in order for
him to successfully join the family system.
A therapist listens to a family’s views of their situation and reframes them in the context of a family’s
structure
Enactments: prompting a family to demonstrate how a particular problem is handled
The family is then directed to continue the enactment or a therapist comments on what went wrong within
the enactment.
Spontaneous behaviour sequences: “like focusing a spotlight on action that occurs without direction”
If acted on early enough, allows for considerable progress through possible therapeutic distractions.
Four sources of family stress:
One member with extra familial forces, whole family with extra familial forces, transition points in the
family's evolution, idiosyncratic problems.
Sets:
Repeated family reactions to stress. Spontaneous sets: interpreted like enactments.
Goals:
clear boundaries as gatekeepers,
clear lines of authority,
systems and subsystems (the parental one is where pathology begins),
increase flexibility to alternative transactions,
help negotiate family life cycle transitions.
Family mapping via diagram of current structure.
“Structural family therapists believe that problems are maintained by a dysfunctional family organization.”
Therapy is therefore directed toward changing the structure to alleviate problems, and activating long
inactive structures already present in a family. Critics wrongfully see this viewpoint as portraying a
“pathological core” in the family, an inherent flaw.
In effect, a structural therapist becomes a part of the system to help its members change it from within.
Boundaries and subsystems are shifted, so the family will have the capacity to solve their own problems.
Enmeshed families will strengthen the boundaries around them while disengaged families will aim to loosen
them.
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Goals to keep in mind, besides the aforementioned structural shift, include formation of a functional family
hierarchy. Parents will operate on the same page, especially when making decisions as family leaders.
Assertion of boundaries of parental subsystem is important to this goal.
How therapy addresses boundaries
Much of the therapeutic work in family systems centres on boundaries, not the physical boundaries of walls
and borders, but psychological boundaries. These types of boundaries can’t be seen or touched, but instead
shape themselves in the form of beliefs, perceptions, convictions, and understandings. Individuals form selfconcepts,
for example, based on beliefs regarding who they are, and these beliefs “surround” individuals,
distinguishing them from others – creating a sense of “otherness.”
These invisible and impactful boundaries are also drawn around groups and subgroups of people. For
instance, parents or couples surround themselves with boundaries that separate them from other couples,
their parents, and their children. Managers in a corporation have boundaries that separate them from coworkers.
Hierarchies are established for a reason, for the proper functioning of the group or organization, to
delegate tasks, and to ensure the proper checks and balances.
Children also form a subgroup within a family, forming a boundary around themselves separate from their
parents. Ideally, the child subgroup holds less power than the parents.
Family systems therapists confront families and situations where boundaries have become crossed,
distorted, or nonexistent. These types of situations lead to dysfunctional and unhealthy relational patterns.
A mother complaining to her child about her spouse - the child’s father - is one example of a crossed
boundary. Another example of a crossed boundary are parents who perhaps share information about their
sexual relationship with their children. These are two examples of distorted boundaries or inappropriate
boundaries that lead to dysfunctional interactions.
No family is perfect, and mistakes often happen. Sometimes more is shared or not enough is shared among
family members, but most families work for an appropriate balance. However, families who allow
boundaries to be constantly, routinely crossed, who set up patterns of interaction and form a family process
that lacks self-regulating behaviours, need help at re-forming boundaries.
Enmeshed and Disengaged families
There are many types of boundary problems - as many problems as there are families. Family systems
therapists assess families for boundary problems along a spectrum, placing boundary problems between the
following two extremes:
◦Enmeshed families. An enmeshed family exhibits signs of smothering, over-sharing, and caring that
reaches beyond normalcy. In enmeshed families, boundaries do not allow for individuation; they are too
fluid, and have become crossed and often distorted. Boundaries are constantly crossed in numerous ways.
◦Disengaged or detached. Families that share little to nothing, typically overly rigid families, are described
as detached. There’s little to no communication – and no flexibility in family patterns to accommodate
effective support and guidance.
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Interventions:
Joining and accomodating (same process: joining emphasizes therapist's outer adjustment to family,
accomodating therapist's inner adjustment; adopting family's affective style;
joining from a distant position = teaching, advice),
mimesis (imitation, or joining from a close position),
tracking (of family communications and behaviour, or joining from a median position),
enactments that simulate transactions to be changed,
detriangulation of IP by forming a coalition with him against a parent,
maintenance (of the family's current structure),
marking boundaries (when they are strengthened, the subsystem's functioning will increase),
mimic IP to show that he's like the powerful therapist rather than deviant, make the IP a cotherapist
to the overfunctioner,
reframing in terms of structure or interaction,
unbalancing by escalating stress,
general restructuring techniques (e.g., rearranging how they sit, blocking certain transactions,
working as a family insider)..
Assessment of therapy
A structural therapist strategically chooses who to talk to first to both facilitate their joining the family and
to gain information on the family’s situation. Once there is comfort with the presenting problem the
therapist expands to the whole family and starts making intelligent guesses about structural concerns.
A family’s responses to exploring the presenting problem are useful in assessing structure. Time is taken to
assess the relationship of the parents in the family.
Four steps identified by Minuchin and his colleagues.
1. Ask questions about the initial complaint so the family begins to see that the problem extends to the
whole family and not just the “problem member.”
2. Help the family see how their interactions may be unintentionally furthering the family’s problems.
3. Briefly explore the family past, particularly to determine how adults have developed the perspectives
currently contributing to the presenting problem.
4. Explore options encouraging productive family interaction, in order to encourage structural change.
Therapy techniques : The seven steps of family therapy
Step 1: joining and accommodating
Unlike individual therapy, a therapist is seen as an outsider to the system initially. Building an alliance,
disarming defences, and offering empathy and expression time to everyone in the group is essential to
joining.
Gentle, understanding, and simple interactions with children are preferred.
Considering who is influential in the family and attempting to join with doubters is especially important in
bypassing resistance.
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Step 2: Enactment
Give each member a chance to talk, to spark enactment.
Enactment, as explained previously, allows for clearer structural inferences due to more direct
demonstration.
Enmeshed families tend to interrupt each other, while disengaged families are more passive while one or
more members are expressing themselves.
Therapists can also view deficiencies in executive control on the part of parents.
Step 3: structural mapping
Broadening the problem from the identified patient to the family structure. Assertions and observations of
structure based on initial sessions are refined over time, especially as the family becomes more familiar with
the therapist, and works through initial chaos.
A combination of the presenting problem and structural observations is the main effort taken in this step.
Step 4: highlighting and modifying interactions
It is important to know when to intervene, and be forceful. Intensity: using a strong and forceful manner of
speaking to exceed familial thresholds of not acknowledging challenges to the way they view their current
situation.
This is a skill involving controlling speaking volume, choice of words, conversational pacing, tone and
other elements of speech. Sometimes this is a matter of repetition across multiple contexts.
shaping competence: “like altering the direction of the flow.” : Reinforcement of desirable patterns and
interactions, in order to highlight the already present functional choices in a client’s repertoire.
Initial therapist mistake is to point out mistakes and give criticism without looking for successes to be
reinforced. This is made up for through observational practice and situational awareness of such successes.
Therapists should avoid taking over for the parents, though some limited argument can be made for
“modelling” of ideal behaviours.
Step 5: boundary making
Strengthening weak boundaries, loosening rigid ones, and establishing parental hierarchy.
In enmeshed families, conversational interruptions and intrusions are prevented. Individual or subgroup
sessions, separate from the rest of the family, may also help
Disengaged families are challenged to not avoid conflict: Differences must be discussed before such
families can come closer. Members of such families have difficulty seeing how their behavior affects others
in the group.
Challenging family members to help each other change is one method of fostering improvement in
disengaged families.
Step 6: unbalancing
As opposed to changes between subsystems, unbalancing aims to change relationships within a subsystem.
Members in conflict and balanced in opposition are stuck, not moving toward progress. A therapist joins an
individual or subsystem and takes sides to unbalance the situation. What may seem like antagonism from
the therapist is actually a challenge for the clients to confront their fear of change.
Unbalancing underscores the key point that families have to be in action to change.
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Step 7: challenging unproductive assumptions
“Changing the way family members relate to each other offers alternative views of their situation.”
The inverse is also true.
This step is accomplished by giving advice or suggestions, with the intention of both familial restructuring
and shaping client perceptions.
“Push” vs. “kick”
Paradoxes are infrequently used by structural therapists, but expression of scepticism of client change can
sometimes help.
Conclusion
While not asserting preference of one method over another, there seems to be support for the effectiveness
of structural therapy in families with drug problems, according to the text. Families dealing with
adolescents with various behavioural problems have been helped. This includes ADHD, conduct disorder
and eating disorders.
Ultimately keep in mind looking beyond dynamics and content and into underlying structure and family
organization.
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Virginia Satir’s Humanistic Family Therapy
One of the founders of the MRI communications school.
Emphasized the importance of giving families hope and building self-esteem in family members.
Key concepts:
**** Also read: Behavioural and Conjoint Family Therapy ****
Turn roles into relationships, rules into guidelines.
Our similarities unite us, and our differences make us grow.
A symptom may be distorting self-growth by trying to alleviate family pain; symptoms are a light
on the dashboard or a ticket into therapy. Broken families follow broken rules. Pathology is a deficit
in growth. What growth price does each part of the system pay to keep the overall balanced?
"Rupture point": where coping skills fail and family needs to change.
Primary triad (mother, father, child) is source of self-identity.
Mind, soul, body triad: a current basis of self-identity.
Self, the core, has eight levels: physical, intellectual, emotional, sensual, interactional, contextual,
nutritional, and spiritual. A good therapist works on all levels.
Three parts to every communication:
Me, you, context. Dysfunctional communications leave one of these out of account.
Games: rescue games, coalition games, lethal games, growth games.
The five freedoms:
To see and hear what is here instead of what should be, was, or will be;
To say what one feels and thinks, instead of what one should;
To feel what one feels, instead of what one ought;
To ask for what one wants, instead of always waiting for permission;
To take risks in one's own behalf, instead of choosing to be only "secure" and not rocking the boat.
Maturation: development of a clear identity and power of choice; self-relatedness; ability to
communicate with others. Coping skills increase with self-esteem.
"Threat and Reward" (rule-makers/followers; rigid roles) vs. "Seed" (innate growth potential)
worldviews.
Five components of self-esteem:
Security, belonging, competence, direction, selfhood.
In a dysfunctional family, symptomatic behaviour makes sense. It is also covertly rewarded.
Interventions:
Reduce individual and family pain.
Family life chronology (three generations).
Communication work and esteem building. Growth.
Identification of family roles, and turning these into relationships.
Family reconstruction: an exercise in which roles in significant family historical events are directed
by the Explorer, who is led by the Guide.
Look at implicit premises that guide perceptions and interactions.
Analysis of how family members handle differentness.
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Cut games, straighten transactions.
Self-manifestation (congruence) analysis.
Model analysis of which models have impacted early on.
Expand experiencing and choice-making.
Parts party: awareness and exercise of mind and body.
Sculpting (group posture) technique.
Labeling assets.
Use of drama, metaphor, art, stories, self.
Criteria for termination:
When family members can complete transactions, check, ask; can interpret hostility; can see how others see
them; can see how they see themselves; can tell each other how he manifests himself; can tell other member
what he hopes, fears, expects from the other; can disagree; can make choices; can learn through practice;
can free selves from harmful effects of past models; can give a clear message, be congruent.
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Behavioural & Conjoint Family Therapy
Family therapists following a communications approach to family therapy hold the view that accurate
communication is the key to solving family problems. (Conjoint family therapy = The involvement of two
or more members of a family in therapy at the same time.)
An open and honest manner of communicating rather than using phony or manipulative roles characterizes
good problem-solving families.
Matching intent and impact of communication.
Gottman built his approach on matching intent and impact of communication.
He used a behavioural interviewing method to teach people about what they are doing that is not working
and to help them correct the situation by learning how to get the impact they want from their
communication.
His stages include
1) exploration,
2) identification of goals,
3) perceptions of issues,
4) selection of one issue for discussion,
5) an analysis of interactions,
6) negotiation of a contract.
Virginia Satir considered herself a detective who helps children figure out their parents. She thought 90% of
what happens in a family is hidden. The family's needs, motives, and communication patterns are included
in this 90%.
She believed that whatever people are doing represents the best they are aware of and the best they can do.
She considered people geared to surviving, growing, and developing close relationships with others.
Self-esteem plays a prominent role in Satir's system.
She viewed mature people as being in touch with their feelings, communicating clearly and effectively, and
accepting differences in others as a chance to learn.
She believed
The four components in a family situation that are subject to change are
1) the members' feelings of self-worth,
2) the family's communication abilities,
3) the system,
4) and the rules of the family.
The three keys to Satir’s system are
1) to increase the self-esteem of all family members,
2) help family members better understand their encounters
3) and use experiential learning to improve interactions.
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Communication and Response Patterns
Communication is the most important factor in Satir's system and determines the kinds of relationships
people have with one another and how people adjust. She discussed response patterns to which people resort
as a reaction to anxiety.
These universal response roles or communication stances are:
Five roles: placater, blamer, super-reasonable, irrelevant, and congruent (or leveling) communicator.
The first four are mostly poses covering lack of self-worth.
1) the placater : an individual who avoids conflict at the cost of his/her integrity
2) the blamer : a person who places blame on others and does not take responsibility for what is
happening.
3) the computer : the super reasonable individual who denies his emotions
4) the distractor : takes irrelevant stances
5) the leveler : Communicates in a congruent way in which genuine expression’s of one’s
feelings are
made in an appropriate context.
Leveling helps people develop healthy personalities; all the others hide real feelings for fear of rejection.
Satir divided families into two types: nurturing and troubled. Each type had varying degrees.
Her main objective for her clients was recognition of their type and then change from type or degree.
The counseling method of conjoint family therapy involves
1) communication,
2) interaction,
3) and general information for the entire family.
She used several techniques to reach her goals of establishing proper environments and assisting family
members in clarifying what they want or hope for themselves and for the family. Her method is designed to
help family members discover what patterns of communication do not work and how to understand and
express their feelings in an open, level manner.
Games
Simulated family games, systems games, and communication games are some of the methods she developed
to deal with family behaviour.
Some of Satir’s games are :
Growth model – assumes that an individual’s behaviour changes due to interactions with other people.
Medical model – purports that the cause of the problem is an illness of the individual.
Sick model – proposes that the individual’s thinking and attitudes are wrong and must be changed.
Filial therapy is a play therapy method based on the principles of child-centered therapy. The goals of
filial therapy are to reduce the child’s problem behaviours, to help parents gain the skills of childcentered
therapist to use as the parents relate to their children and to improve the parent-child
relationship.
Strategic family play therapy is a form of counseling in which all family members and the counsellor
play.
Theraplay is a treatment method modeled after the healthy parent-child interaction in which parents are
involved first as observers and then as co-therapists.
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The Counsellor’s Role
The counsellor's role in this model is of a facilitator who gives total commitment and attention to the
process and the interactions. The counsellor intervenes to assist leveling and taking responsibility for one's
own actions and feelings.
Play therapy with families has the advantage of helping children communicate their story to the therapist.
Dynamic family play therapy engages family members in creative activity by using natural play.
The counsellor’s goal is to help the family develop and increase spontaneity.
Key Concepts
1. The individual is considered as part of a family and the interactions and relationships within the
family are the focus of therapy.
2. The systems approach to family therapy is focused on how family members can maintain a healthy
balance between being enmeshed and being disengaged.
3. Structural family therapy is based on the idea that the family is an evolving, hierarchical
organization made up of several subsystems with rules and behaviour patterns for interacting across
and within those subsystems.
4. According to structural theorists, defining and clarifying boundaries that exist between subsystems
is imperative.
5. Minuchin's approach is directed toward changing the family structure or organization as a way of
modifying family members' behaviour.
6. Strategic family therapy is based on the assumption that the family's ineffective problem solving
develops and maintains symptoms.
7. Conjoint family therapy is based on honest communication, members’ feelings of self-worth, and
the rules of the family.
8. Some of the family play therapy approaches include dynamic family play therapy, filial therapy,
strategic family play therapy and thera-play.
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Milan Systemic Family Therapy
or “Long Brief Therapy”
Led by Mara Selvini-Palazzoli.
Sessions held about once a month to let things incubate; families wanting more are trying to control
the therapy. Neutral, nonreactive therapist who asks family to generate its own solutions.
Key Concepts:
Emphasis on information, paradox, circular feedback loops.
Repetitive interactions: games by which members try to control one another. Change the interactions
and the behaviour will too.
Dysfunctional families make an "epistemological error" that can be corrected.
Therapy:
one or two therapists see the family while a team watches from behind a mirror.
Sessions broken by an intersession during which the therapist talks to the team away from the family.
Interventions:
Counterparadox.
Pre-session hypothesizing.
Circular and triadic questioning.
Positive connotation of a behaviour's intent.
Assignment of rituals.
Invariant prescription to loosen parent-child collusion.
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Excerpt from an Article by Lorraine M. Wright and Wendy L. Watson, University of Calgary:
Systemic family therapy owes its origins to the brilliantly creative and innovative clinics team of M.
Selvini-Palazzoli, L. Boscolo. G. Cecchin. and G. Prata (1978 - 1980). These four Italian psychiatrists have
had an enormous impact on the conceptualization and practice of Family Therapy in the I98Os in North
America and throughout the world.
Systemic family assessments focus on family relationships, family development, alliances/coalitions and the
process of communication between family members. The three fundamental principles necessary to
conducting a systemic interview are hypothesizing, circularity, and neutrality (Selvini-Palazzoli et al.
1980). All three of these principles are interrelated.
Assessment
The assessment process is based on the formulation of hypotheses by the therapist about the family
organizational patterns connected to the problem.
The therapist first gleans information about a family
- From intake data.
- From previous experience with other clinical families, and
- From various theories and research regarding the presenting problem or the "type" of family
and then generates one or two initial working hypotheses (Fleuridas. Nelson, Nr Rosenthal, 1986).
Family development theories can be useful in pointing the therapist to "tasks" and attachments that may be
taxing the presenting family.
Throughout an interview, questions are asked in order to validate or invalidate alternative hypotheses. Based
on the information gathered from the family, the therapist modifies or alters his or her hypotheses about the
problem and about the family and continually moves to a more "useful" understanding of the family.
In our view, the hardest work that occurs in systemic therapy is in developing systemic hypotheses.
Linear hypotheses are so much easier to generate, particularly judgmental linear hypotheses (e.g. a mother is
too controlling of a father). Systemic hypotheses connect the behaviors of all family members in a
meaningful manner (Tomm, 1984b). (For example, a father shows little initiative or concern regarding his
future. The less concern he shows, the more concern his wife shows: eventually, she directs him in what to
do. The more she directs him, the less he directs himself. And vice versa).
"Circularity" refers to the therapist's ability to develop systemic hypotheses about the family based on the
feedback obtained during questioning about relationships (Selvini-Palazzoli et al., 1980). Circularity is
based on Bateson's (1979) idea that "information consists of differences that make a difference"
(p. 99).
Differences between perceptions/objects/events ideas/etc. are regarded as the basic source of all information
and consequent knowledge. On closer examination, one can see that such relationships are always reciprocal
or circular. If she is shorter than he, then he is taller than she. If she is dominant, then he is submissive. If
one member of the family is defined as being bad, then the others are being defined as being good. Even at a
very simple level, a circular orientation allows implicit information to become more explicit and offers
alternative points of view. A linear orientation on the other hand is narrow and restrictive and tends to mask
important data. (Tornm. 1981, p. 93)
Circular questioning involves the ability of the therapist to conduct the assessment on the basis of obtaining
information about relationships (Selvini- PalazzoIi et al, 1980).
Linear questions tend to explore individual characteristics or events (e.g., How long have you had angina'!),
whereas circular questions tend to explore relationships or differences (e.g., Who in your family is the most
confident that you can manage your heart problem? (Selvini-PalazzoIi, et al., 1980; Tomm, 1981, 1985).
If the therapist wants to validate or invalidate the hypothesis that a family is having trouble launching the
eldest daughter, a useful circular question, directed to other children in the family, could be, "What will be
different in the family when Susan leaves home'!"
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Interventive (reflexive) questions induce a family to reflect and therefore think and act in a new way
(Tomm, 19871). Although many kinds of questions have the potential for inducing new cognition, affect,
and behavior, all questions are not created equal!
Using the preceding family situation, consider the fallowing interventive developmental question, directed
to the parents of Susan: "If you decided to convince Susan that she was ready to leave home, how would
you go about it?"
"Neutrality,” the third principle of systemic assessments, refers to the ability of the therapist to respond
without judgment or blame to problems, change, persons, and various descriptions of relationships.
For example, if a family makes a connection between a developmental problem, such as a young adult's
reluctance to leave home, and their belief that it is due to the young adult's having a chronic illness, the
therapist would be as neutral as possible in his or her reactions to this description, but it does not mean that
the therapist has to accept this connection. The assessment information obtained through circular
questioning about the meaning and belief of developmental problems will greatly assist the therapist in
intervening. However, it must be emphasized chat it is necessary to intervene only if particular beliefs
interfere with or block the problem-solving efforts.
Family Development through a systemic lens
In the systemic approach, families are viewed as self-regulating systems controlled by rules established over
time through a process of trial and error (Selvini-Rlazzoli et al., 1978). If the rules do not allow for a natural
progression through various family life cycle stages or for an accidental shift (e.g., chronic illness, divorce),
a family member may develop a symptom as a "solution" to helping the family progress along its
evolutionary path (Hoffman, 1981; Tomm, 1984a). The symptom, or presenting problem, represents an
interactional dilemma chat is derived from particular family beliefs. In this model, one of the therapist's
goals is to offer the family an alternate "belief' or "reality" about the problem, which may then allow the
family to discover its own solutions. More specifically, the therapist aims first at understanding the family's
reality surrounding the problem and then at challenging this reality by introducing "new connections"
between relationships, beliefs and behaviors.
The family finds its own solutions once its ability to change has increased. This is accomplished following a
change in the "reality" of, or in the beliefs about, the problem: new views of old problems (Ugazzio (1985)
emphasizes that the first phase of any systemic interview should focus on the family's interpersonal belief
system and should explore family members' explanations, interpretations and attributions of meaning and
intentionality for their own and other members' behaviours. We concur with this focus and make it a
routine pattern of our clinical practice to explore consciously and deliberately family members' beliefs about
and meanings for the presenting problem (i.e., cause. cure, consequences).
Systemic therapists do not adhere to the belief that the past determines the present or the future. Rather, they
find it more helpful, from a systems view, to believe that the past can illuminate the present and vice versa.
The systemic lens enhances the therapist’s ability to view the past in a variety of ways.
Most family life cycle stages are highlighted by the addition and/or departure of family members. The stage
of families launching children is perhaps the most dramatic and traumatic in this respect. It is punctuated
with numerous entries and exits of family members: the departure of young adult children, the addition of
sons- or daughters-in-law and the attrition by death of the grandparent generation. Families frequently find
themselves involved in a series of adjustments and readjustments at this stage of development. How families
cope with this particular stage is hest understood if a three generational view is taken (McCullough. 1980).
For example, the amount of success parents encountered in dealing with autonomy and separation issues
with their families of origin will, in turn have a definite impact on their ability to deal successfully with
these issues with their own grown children (McCullough.1980).
When a family encounters difficulty in accomplishing the task of parent-child separation, it is usually
manifested in one of two ways (Wright, Hall, O'Connor, Perry. & Murphy, 1982), Wright et al (1982)
indicate that one common response is for parents and children to be so loyal to the nuclear family that they
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disregard their own individual development. In families characterized by a high degree of loyalty, it is often
difficult for the young adult to individuate because individuation may be seen by the family as a form of
rejection. Some young adults respond to this dilemma by remaining highly dependent on their parents for
emotional and – sometimes - economic support and they often provide companionship and nurturing for one
or both parents.
The second extreme response of families negotiating the launching stage is for parents and children to
distance themselves emotionally from each other to such an extent that they appear to be totally
disinterested in each other and totally consumed by self-interest. For example, young adults may
declare their independence and cut ties completely with their family in an effort to individuate.
Determining what direction a relationship should take is not the primary goal of the clinicians. Rather, the
aim of the systemic therapy team is to create a context for change and to offer an alternate epistemology of
the problem so that the family can discover their own solutions. Therapists must trust the solutions that
families find and must recognize that the pace the family takes roward problem solving is often different
from that which the therapist might establish (e.g., sometimes much slower, sometimes much Faster).
One way a therapist can induce a family system to find the direction and pace of its solutions, is to accept
each family member's perception of the problem and to offer an alternate view, or "reality," of the problem,
The aim of this systemic perturhation is to enhance the autonomy of the system.
The challenge for the therapist is not to become "married" to the alternate reality that is presented to the
family or lo think it more correct than the view a famiIy holds. It is, at best, a more useful view, in the sense
that the new reality frees up the problem-solving ability of the system. There are more realities than there
are families and these realities only need to be modified when they inhibit individual or family
development.
An important difference between this model and other family therapy models is that the systemic approach
utilizes a non-normative model of family functioning while recognizing that there clearly exist various
developmental transitions and stages. (It is intriguing to us that an understanding of a normative model
enhances the learning of a non-normative rnodel). However, systemic therapists work against the impulse to
direct families as to how they should function or develop. The use of the split-opinion intervention in which
one therapist supports the solution of one family member, a second team member supports the solution of
another family member and a third therapist advances an alternative solution, is an excellent illustration of
how to intervene not only with the family , but also with the therapeutic team, to prevent the latter from
pushing the family to change in a particular direction and/or at a particular pace. If famiIies are influenced
in a particular direction, that will, in turn, direct family development and/or fami!y functioning.
The process of change
To facilitate change in a family system is he most challenging and exciting aspect of family therapy. The
process of change is a fascinating phenomenon, and various ideas exist about how and what constitutes
change in family systems. Liddle (1982) has suggested that one of the basic issues of all of us who engage
in family therapy is the interviewer's theory of change, that is: what mechanisms permit or force change to
occur? Even more basic: what is the nature of change itself according to one's own model? (p. 248). We
concur with Bateson's (1979) notion that systems of relationships appear to possess a tendency toward
progressive change. However, there is n French proverb that states, "plus ça change, plus c'est la même
chose" ("The more something changes, the more it remains the same.") This highlights the quandary
frequently faced in working with families. Systemic therapists must learn to accept the challenge posed by
the relationship between persistence (stability) and change. Watzlawick, Weakland and Fisch (1974)
suggest that persistence and change need to be considered to together despite their opposing natures.
They have offered a notion of change that is accepted by most systemic therapists, which is that there are
two different types or levels of change.
One type they refer to is first-order change, or change that occurs within a given system. That is, in the
elements or parts of the system, without changing the system itself. It is a change in quantity, not quality.
First-order change involves using the same problem-solving strategies over and over again. If a solution to a
problem is difficult to find, more old strategies are used, and they are usually applied more zealously.
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Second-order change is change that alters the system itself. This type of change is thus a "change of
change."
It appears that the French proverb is applicable only to first-order change. In second-order change, there are
actual changes in the rules governing the system, and therefore the system is transformed structurally and/or
communicationally. Second-order change always involves a discontinuity and tends to be sudden and
radical: it represents a quantum leap in the system to a different level of functioning.
Systemic therapy focuses on facilitating second-order change. Our case example beautifully exemplified
changes that were dramatic and rapid. A change occurred in the system itself, in addition to a change in the
presenting problem.
In summary, we concur with Bateson (1979) that change is constantly evolving in families and that
frequently we are unaware or change. This is the type of continuous or spontaneous change that occurs with
everyday living and with progression through individual and family stages of development.
These changes may or may not occur with professional input. We also believe that major transformations of
an entire family system can he precipitated by major life events and / or interventions by family therapists.
We view change as a systems/cybernetic phenomenon; that is, change within a family may occur within the
cognitive, affective, or behavioral domains, hut change in any one domain will have an impact on the other
domains. However, we believe that the most profound and sustaining change will be that which occurs
within the family's belief system (cognition).
There are certain concepts regarding change we have found particularly useful in our systemic clinical work
with Families. We will discuss the two most salient concepts here.
First, the ability to alter one's perception of a problem enhances the ability for change (Wright & Leahey,
1984). It is essential that both family members and family therapists alter their perceptions of a problem. If a
therapist agrees with the way a family views a problem, then nothing new will be offered. How we, as
therapists, perceive and conceptualize a particular problem determines how we will intervene.
When a therapist conceptualizes developmenta1 problems from systems/ cybernetic perspective, his or her
perceptions will be based on a completely different conception of "reality" as a result of these theoretical
assumptions.
Our clinical practice with families who present at the FNU with developmental problems is based on a
systemic-cybernetic-communicational theoretical foundation. Interventions are based primarily on the
systemic model (Selvini-Palazzoli et al, 1980; Tomm. 1984a, 1984b). These are some of our efforts to think
systemically. But what of families?
Individual family members construct their own realities of a situation based on personal beliefs and
assumptions. Families and family members need assistance in moving from a linear perspective of the
problem to a circular one. This is possible only if the therapist doesn't become caught in linear thinking
when attempting to understand family dynamics.
We have found that one way to avoid becoming linear in conceptualizing developmental problems is to
avoid thinking that the view of a particular family member or of all family members are "right" or correct.''
The challenging position of the therapist is to offer an alternate perception, reality, or epistemology
that will free the family to develop is own solutions to the problems. This alternate reality is usually
redefined as an interpersonal or relationship problem.
The second salient concept is that change does not occur as a result of therapeutic elaboration of a family's
understanding of developmental problems. In our clinical experience, we have rarely found that changes or
improvements regarding developmental issues occur by embellishing a family's view of the problem.
Rather, we have observed that the solutions to problems change as the family's beliefs and interactional
patterns change whether or not this is accompanied by further insight. Systemic therapy avoids the search
for lineal causes and seeks, instead, to provide systemic explanations of problems and impasses.
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Roadblocks to family developmental change
Family therapists regardless of theoretical orientation have noticed that many families have not progressed
smoothly or automatically from one life cycle stage to another. Their clinical interventions focus on the
stressful transition points between stages. Certainly, in our own clinical work, we have sometimes
succumbed to the temptation to focus on particular transition points that have become problematic. The
potential trap is for systemic therapists to become too purposive, that is: to become too invested in a
particular outcome and to then direct the family to function or be restructured in a particular way.
Systemic therapists try not to "get in the way" of family development by not being directly directive. Thus
the notion that families must progress smoothly through the famity life cycle stages must he confronted.
Smooth progression, in our estimation, is not characteristic of a developing family. However. there are
occasions when families have "derailments from the family life cycle" (Caster & McGoldrick, 1980 p. 9).
This notion of derailments is useful, because it conjures up a much more optimistic view of family life
cycle difficulties.
One of the most common derailments that we encounter in our practice is the derailment by illness. The
impact on the family of a chronic or life-threatening illness does not automatically result in a derailment, but
it almost always interferes with roles, rules and rituals. From a systemic perspective, a derailment also
frequently occurs when family members are attempting to obtain meaning and clarification in a relationship.
The greater the ambiguity regarding relationships, particularly at various developmental junctures
throughout the family life cycle, the greater the chance for family and individual symptoms.
With any derailment, it should not necessarily be the therapist's goal to have the family return to the original
"track." Rather, it behooves the therapist to create a context for change for the family to allow them to
decide which track will provide the greatest opportunity for reduced stress and increased growth.
Interventions that create a context for developmental change.
There are numerous interventions that can be utilized to facilitate or create a context for change. However,
we will discuss only systemic interventions that create a context for developmental change.
Offering alternate realities
Systemic family therapists frequently offer beliefs, opinions or conceptions about problems without
regarding them as interventions. However, when strategically thought out and planned, these various types
of opinions serve as potent and useful interventions offering an alternate reality to those experiencing
particular problems.
1. Information and advice.
Families find advice and information about developmental problems valuable and beneficial. Frequently,
Information about developmental issues e.g., elderly parents' needs for "spatial but not social isolation" and
for "autonomy with contact" (Banziger, 1979) can liberate a family so that the members are then able to
resolve their own problems.
2. Systemic opinion (reframing)
Presenting symptoms may serve a positive function for a family. A systemic opinion is offered by
conceptualizing the presenting symptom as a solution to some other hypothetical or implied problem that
would or could occur should the symptom not be present (Tomm, 1984b). In the case example, the intense
inter-generational conflict was positively connoted as a distance regulator in an overly close parent-child
relationship. The symptomatic behavior is systemically reframed by connecting it to other behaviors in the
system. The connections are based on the information derived in the assessment through the process of
circular questioning. It is essential. when offering a systemic opinion to a family, that the reclusiveness of
the symptom be delineated: The symptom serves a positive function for the system while at the same time
the system serves a function by contributing and maintaining the symptom (Wright & Leahey. 1987).
3. Redefinition of the context of therapy
A powerful opinion can be given by redefining the context in which family therapy is provided. If a family
objects to attending sessions for what they have defined as Family therapy, then, based on the assessment,
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the family could be told that family therapy sessions will be discontinued and that developmental sessions
will begin (Wright & Watson, 1982). It is not that the nature of the work between the therapist and the
family changes, but rather that the context, or "name," of the work is made more palatable. With the family
described in the case example the nature OF our work was named research rather than therapy.
4. Commendation for family and individual strength
Following a recent analysis, by three observers, of 28 sessions we conducted with Tour families in a
hypertension project, one of the common themes identified was our routine practice of commending
families on particular strengths at the end of interviews. Feedback from both research observers and families
has made us cognizant that this practice involves more than just being courteous-it represents a significant
intervention that can alter family members' realities of themselves.
5. Split option.
We have found the split-opinion to be a most powerful systemic intervention. Normally, a split opinion
offers the family two or more different and opposing views. Each point of view is equally valued and the
family is left to struggle with the various views or reality. The split-option enables each participating family
member to have their view of reality strongly supported while at the same time providing each with the
opportunity to entertain a totally new epistemology with regard to the presenting problem. This intervention
creates a context for change that has previously been impossible, possibly because of the extreme rigidity of
each family member's beliefs.
In designing and prescribing a ritual, a therapist requires that a family engage in behaviors that have not
been part of their usual patterns of interaction. The existence of contusion is normally an indicator for the
use of the ritual intervention.
The confusion is due to the simultaneous presentation of incompatible injunctions within the family. Rituals
introduce more clarity into the family system. In systemic work, the actual execution of the ritual is not as
important as the feedback about what new connections the family has made and consequently what new
beliefs or realities the family now entertains.
In a case, two rituals were prescribed:
The "meeting of the hearts" technique, which involves ritualizing a talking-listening session.
The "burial of the hurts so the hearts can heal", which provides a forum for further purging.
The second ritual was not executed because the parties involved stated that “there ere no more bad feelings
left”
Selvini-Palazzoli (1986) indicated that some families respond just to the idea of doing something unusual.
Thus the enactment of the prescribed ritual may not be essential to induce a change in the family system.
Useful information to the family and the therapist may he provided through just the description/prescription
of a ritual.
Conclusion
Traditional life cycle theorists and therapists imply with their clearly demarcated stages, tasks, and
attachments, "WE know how your family should function.''
Systemic therapists use life cycle information to generate
( I ) working hypotheses about the connection between the symptom and the system and
(2) questions to perturb the family system, so that the family can answer its own question, "What is the
most useful way for our family to function at this time'?"
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Response-based Family Therapy
From Wikipedia, the free encyclopedia
Response-based therapy is a relatively new psychotherapeutic approach to treating psychological trauma
resulting from violence, based on the theory that whenever people are treated badly, they resist.
Incorporating elements of Solution focused brief therapy, Narrative therapy, and discourse analysis.
It was first proposed by a Canadian family therapist and researcher, Dr. Allan Wade, in his 1997 article
"Small Acts of Living: Everyday Resistance to Violence and Other Forms of Oppression.
Therapeutic Methods
Therapeutic methods of response-based therapy are based on two theoretical foundations:
(1) That alongside accounts of violence in history, there exists an often-unrecognized parallel history of
"determined, prudent, and creative resistance," and
(2) Language is frequently used in a manner that
(a) conceals violence,
(b) obscures and mitigates perpetrator responsibility,
(c) conceals victims' resistance, and
(d) blames or pathologizes victims.
This second principle employs "discourse analysis" and is referred to in response based therapy as the "four
discursive operations."
This presupposition of resistance as a natural response to violence is used to engage clients in in-depth
conversations about how they responded to specific acts of violence.
In response-based literature, resistance is defined and examples given:
“Any mental or behavioural act through which a person attempts to expose, withstand, repel, stop, prevent,
abstain from, strive against, impede, refuse to comply with, or oppose any form of violence or oppression
(including any type of disrespect), or the conditions that make such acts possible, may be understood a a
form of resistance.” (Wade, 1997, p. 25)
“Whenever people are abused, they do many things to oppose the abuse and to keep their dignity and their
self-respect. This is called resistance. The resistance might include not doing what the perpetrator wants
them to do, standing up against, and trying to stop or prevent violence, disrespect, or oppression. Imagining
a better life may also be a way that victims resist abuse.” (Calgary Women’s Emergency Shelter, 2007)
Therapy consists of using language to
(1) expose violence,
(2) clarify perpetrators' responsibility,
(3) elucidate and honor victims' resistance, and
(4) contest victim blaming .
In response-based therapy, the client is viewed as an "agent" who has the capability to respond to an act,
rather than a passive "object" that is "acted upon."
Example: the response-based therapist would not ask a victim "How did that make you feel?", but instead
would ask "When [act of violence] was done to you, how did you respond? What did you do?"
160

References
1. ^ Wade, 1997, p. 23
2. ^ Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of
oppression. Contemporary Family Therapy, 19(1), 23-39
3. ^ Coates, L., & Wade, A. (2004). Telling It Like It Isn’t: Obscuring Perpetrator Responsibility for
Violent Crime. Discourse and Society, 15(5), 3-30.
4. ^ Todd, N. & Wade, A. (2003) 'Coming to Terms with Violence and Resistance: From a Language
of Effects to a Language of Responses', in T. Strong & D. Pare (eds), Furthering Talk: Advances in
the Discursive Therapies, New York: Kluwer Academic Plenum. p. 152.
Related Reading
• Calgary Women's Emergency Shelter. (2007). Honouring Resistance: How Women Resist Abuse in
Intimate Relationships (formerly Resistance to Violence and Abuse in Intimate Relationships: A
Response-Based Perspective) Available from Calgary Women's Emergency Shelter, P.O. Box
52051 Edmonton Trail N., Calgary, Alberta T2E 8K9.
• Coates, L. & Wade, A. (2004). Telling It Like It Isn’t: Obscuring Perpetrator Responsibility for
Violent Crime. Discourse and Society, 15(5), 3-30.
• Coates, L. & Wade, A. (2007). Language and Violence: Analysis of Four Discursive Operations.
Journal of Family Violence, 22(7), 511-522.
• Todd, N. and Wade, A. (2001). The Language of Responses Versus the Language of Effects:
Turning Victims into Perpetrators and Perpetrators into Victims, unpublished manuscript, Duncan,
British Columbia, Canada.
• Todd, N. & Wade, A. (2003). 'Coming to Terms with Violence and Resistance: From a Language of
Effects to a Language of Responses', in T. Strong & D. Pare (eds), Furthering Talk: Advances in the
Discursive Therapies, New York: Kluwer Academic Plenum.
• Wade, A. (1997). Small Acts of Living: Everyday Resistance to Violence and Other Forms of
Oppression, Journal of Contemporary Family Therapy, 19, 23–40.
• Wade, A. (1999). Resistance to Interpersonal Violence: Implications for the practice of therapy.
University of Victoria, Ph.D. Dissertation, Department of Psychology.
• Wade, A. (2007a). Despair, resistance, hope: Response-based therapy with victims of violence. In
C. Flaskas, I. McCarthy, and J. Sheehan (Eds.), Hope and despair in narrative and family therapy:
Adversity, forgiveness and reconciliation (pp. 63–74). New York , NY : Routledge/Taylor &
Francis Group. HF
• Wade, A. (2007b). Coming to Terms with Violence: A Response-Based Approach to Therapy,
Research and Community Action. Yaletown Family Therapy: Therapeutic Conversations. [2]
• Weaver, J., Samantaraya, L., & Todd. N. (2005). The Response-Based Approach in Working with
Perpetrators Of Violence: An Investigation. Calgary Women's Emergency Shelter [3]
161

Contextual Family Therapy Approach
“Without a moral vocabulary, we cannot act out of conviction, merely out of habit.” (Susan Neiman)
The field of this essay is the Contextual Approach to Family Therapy, developed in the mid-20 th century. Its
founder, Iván Böszörményi-Nagy (1920-2007) was born in Budapest into a family of prominent judges,
graduated with a Degree in Psychiatry in 1948 and immigrated to the US, in disagreement with unjust
Communist regime in post - WWII Hungary.
Family Therapy started developing in
1950s, when several American
therapists, including Böszörményi-Nagy
“began to look beyond individual
psychology to understand and try to
treat severe mental disorders...” (Carey
(2007)) During clinical work,
Böszörményi-Nagy noticed destructive
patterns of family interactions being
frequently passed on through
generations. This observation later
contributed to the Contextual Approach,
which equipped Family Therapy with
new theoretical principles and practical
applications.
The word “Context” has significant
meaning within Contextual Approach in
general and the Relational Ethics in
particular. It differs from the ordinary
one in the idea of responsibility of
everybody participating in the
relationship for the latter. “Context”
indicates that clients are dynamically
connected to their long-term relational involvements and multigenerational roots. It refers to network of
contacts, built in the process of giving and receiving and Interdependence, created as a result.
Relational Ethics through Multi-generational Perspective focuses on both intra- and inter-generational
functions and roles of Loyalty to both Family and Society (rather than submission to power), Legacy,
Fairness, Accountability, Trustworthiness and Reciprocity. Deriving from basic needs and individual
experiences, Relational Ethics are more than a code of socially accepted behrs. In all its complexity
mankind can be legitimately seen as either essentially selfish, or altruistic and good natured, or morally
ambivalent. However, “our evolutionary inheritance shows that “we are moral beings to the core” (de Waal,
cited by Labanyi (2009), p.21) Therefore, in the opinions of many, Relational Ethics is naturally present in
individuals, Families and broader society
The core of Contextual Approach rests on two postulates.
Firstly it holds that all Family members bare consequences of each other's actions or inactions.
Secondly it states that “quality of one's relationships is inseparable from the responsible consideration of
those consequences for others.” (Fowers, Wagner (1997))
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Four-Dimensional Interventions
As both a guide for therapeutic interventions and a theoretical concept, Contextual Approach originally
proposed four inter-connected, but not equitable or reducible to each other dimensions of Relational Reality;
namely
Facts,
Individual Psychology,
Transactions and
Relational Ethics.
Böszörményi-Nagy introduced the fifth, “ontic dimension” in 2000, although it was implicitly present
within the original theory. (Kalayjian, Paloutzian (2009), p.43)
Facts
The first dimension - Facts - consists of factual reality and biological determines, over which we have
limited or no control. Many facts and events occurring in the Families or Societies (immigration, large lotto
winnings, unemployment, adoptions, particularly intercultural ones, births, deaths, ethnic and religious
conflicts) impact on the Family relationships, change interaction patterns, and deeply affect both individual
and Family goals. Along with biological and historical determines this can create conflicts within the
Family, which, if unresolved can become factual realities, creating grounds for “split-loyalty.” (Krasner,
Joyce (1995), p.19) When more than one generation of the Family become involved in such unresolved
conflict, consequences of action or inaction of one generation can become a legacy, passed down to
descendants. These events were termed “created realities.” (Fowers, Wagner (1997))
This Multi-generational Perspective bears huge significance within all dimensions of Contextual Approach,
and has become probably one of the most important contributions of Böszörményi-Nagy to Contextual
Approach. It empowers Family Therapy with new keys to understanding Family development and
interactions. Shpungina (2009) describes how limitations of civil rights of Jews in Russian Empire in 18 th -
19 th centuries resulted in formation of closer bonds within Families, which have been passed down through
generations. These traits are present in many Families of their descendants until now. On the contrary
Voronov (2009) gives examples of Family disintegration as a result of individual Family members' loyalties
being split between Family and Society in 1920s Russia.
Individual Psychology
The second dimension of Contextual Approach - Individual Psychology - refers to the internal world of
individual Family members and “includes cognitions, emotions, fantasies and other symbolic processes.”
(Böszörményi-Nagy (1991), cited by Piercy, Sprenkle, Wetchler (1996), p. 28) Opposite “to the Systemic
Approach, where the individual was often lost,” (Gangamma, p. 11 ) Contextual Theory holds that the same
processes affect developments of both Family and individual Family members. People differ in strengths
and limitations, cognitive and coping abilities and techniques. In the Therapeutic setting “failing to see
individual’s personal concerns, thoughts, wishes, hopes, past hurts, and disappointments can lead … to ...
errors” (Goldenthal (2005), p. 23) in Family therapy as much as in individual one. Within this discovery
lies yet another contribution of Böszörményi-Nagy, a trained Psychoanalyst, to Contextual Approach –
incorporation of elements of the Psychoanylatic theories within the Systemic Theories in the form of
recognition of influence of an individual on the Family development and responsibility for facilitating
change in Therapy process. It is important to emphasise that according to Böszörményi-Nagy's Contextual
Approach, individual factors are always looked at in the relational context, because “to be is to be
relational.” (Lothstein (1996) cited by Gangamma, p. 11) This contribution of Böszörményi-Nagy found its
practical application in Therapy in forms of Acknowledgement and Assessment of individual psychological
differences.
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Transactions
The third dimension of Contextual Theory – Transactions - refers to the interaction patterns in Families that
are reciprocally affected by its members. Although both Contextual and Systemic Approaches agree on
circular nature of relationships, the former sees Families as dynamic self-regulatory systems (Whitchurch &
Constantine (1993) cited by Gangamma, p. 12) in the state of permanent fluctuation of structure, roles and
communication patterns, functioning
to produce change in patterns or to
maintain status quo. According to the
Contextual Approach, every
individual strives for identity and
boundaries. Our identities only exist
in comparison to others. As social
beings we need complementarity in
meaningful relationships in the
Family, when “the other would no
longer be seen as superior or inferior
...”, which produces “...a less rigid
form of identity with which we make
contrast between “us” and “them.”
(Chaplin (2008), p.25) In this context
the fulfilment of goals and needs of
both the individual and the Family
defines a healthy family in the framework of Contextual Approach.
Relational Ethics
Probably the most significant contribution of Böszörményi-Nagy to Contextual Approach is the
development of its forth dimension – the ground breaking concept of Relational Ethics. Böszörményi-Nagy
strongly believed that our evolution, health and even survival depend on quality of human relationships. In
this context Relational Ethics consider mutual Trust, Loyalty, and Sincerity to be the key conditions of
strong relationships and united Families.
Böszörményi-Nagy was among the first Theorists who acknowledged that “Family Therapy and moral
questions are inseparable,” and to locate the “ethical dimension of family life and therapy at the centre.”
(Fowers, Wagner, (1997)) He also contributed to the field of Family Therapy by offering “positive practical
recommendations about the way to approach the moral dimension of Family Therapy.” (Fowers, Wagner,
(1997))
Critics
Some authors see Böszörményi-Nagy's emphasis on universally appealing ideas of Trustworthiness and
Fairness as a limitation rather than a strength, because it “provides a limited view of the good in Family
life.” (Fowers, Wagner, (1997))
When it comes to defining Fairness and Justice, Böszörményi-Nagy leaves it to Families. This allows for
“value-neutrality,” which in our age of “political correctness” is seen by many as a strength of the
Approach. However, Labanyi (2009, p. 22) argues that being a Therapist means to be “willing to extend our
thinking beyond our “safe” and introverted rituals.”
Value - neutrality always raises questions. If Justice can be defined by mutual agreement of Family
members, why the centuries-long debate on it is not yet resolved? Would children, elderly and disabled
have their say in the discussion? Would the negotiation allow for gender equality and split loyalties? The
same applies to Fairness. Their definitions vary in Families and societies of different backgrounds.
Ulitskaya (2007) gives examples of irreconcilable differences in definition of Justice and Loyalty in multi–
cultural immigrant families in Israel in 1960s. Importance of Connectedness and Trustworthiness can be
reduced to zero in favour of other socially accepted values. Changes in the value of Honour and Obedience
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versus Connectedness and Trust over time within ethnic minorities in England and in Afganistan are
discussed by Sanghera (2009) and Hosseini (2007). Despite undeniable importance of Böszörményi-Nagy's
Ethical concepts, inability to provide practical solutions for reconciliation of legitimate differences in
understanding of morals can be seen as one of the limitations of the Approach. It is not entirely free of
distortions and biases, therefore the Relational Ethics, operating within “none-imposed,” but latently present
Western moral code fails to provide the “general approach to moral considerations in therapy.” (Fowers,
Wagner, (1997))
Despite being open to interpretations all Family interactions are acts of giving and receiving. Each of the
them brings a new balance or imbalance to the Ledgers of entitlement and indebtedness. This accounting
metaphor is used by Böszörményi-Nagy to discuss the balance of give and take in the Family. Because
Contextual Approach defines the Trustworthy relationships as mature and free of exploitation, in its
framework a Ledger is balanced when Family members take responsibility for making an honest effort to
consider each other's interests, rather than make a contribution of “equal value.”
Entitlement
Deriving from the metaphor of “Ledger,” the concept of Entitlement relates to Family members' ability to
prioritise other's needs, welfare, and interests over their own. In a fair exchange of give and take a
constructive Entitlement is earned. Those subjected to unjust factual realities acquire destructive
Entitlements and are more than likely to compensate for this violations.
Although both experiences will probably be brought forward, understandably compensations for destructive
entitlements spanning trough generations are spoken about more often. Böszörményi-Nagy believed that his
Approach applied to all relationship, including society as a whole. According to Kurimay, he holds that all
relational conflicts are results of destructive Entitlements, whether it is “ethnic war in Sarajevo, race riots in
Los Angeles, substance abuse on the street corner, or unhappy “adult children” in your house.” In another
words, Böszörményi-Nagy's contributes to the Approach by offering a logical explanation as to why some
individuals are “predisposed to engage in repetitive and harmful behaviours that often affect those that did
not victimize them and therefore are innocent.” ( Böszörményi-Nagy's & Krasner (1986), cited by
Gangamma (2008), p.2)
Böszörményi-Nagy believed in the usefulness of the Contextual Approach so strongly, that he suggested the
use of it for “the possible mediation between cultures and religions after 9/11.” (Kurimay) Whether or not it
is too naive to suggest that Contextual Approach can be as successful in resolution of international conflicts
as it is in resolution of Family ones remains to be seen. Even if strength of the Approach can not be
stretched that far, it is undoubtedly a useful tool for many areas of Therapy. For instance, according to
Adkins (2010) Contextual Approach “offers a new lens through which one can explain Intimate Partner
Violence,” (p 29-30) and fills many other gaps in the existing theories, attempting to explain “femail's
violence toward male partners and violence in same-sex relationships.” (p. 30)
Placing a high value on Closeness between Family members and their significance for the development of
relationships, Böszörményi-Nagy proposed the fifth – Ontic - dimension of Contextual Approach, which
refers to the nature of the interconnectedness between people that allows an individual to exist decisively as
a person, and not just a “self.”
Although as any theory Contextual Approach has both its strengths and limitations, contributions of
Böszörményi-Nagy to its development can hardly be overstated. He was probably the first one to recognise
inseparability of behavioural and Ethical dimensions. The latter has become an important and integral part
of many Approaches to both Family and Individual Therapy. Perhaps because of this discovery Contextual
Approach seems to capture nature of Family relationships in all their complexity, including multigenerational
dynamic, “better than any other major Family Therapy Approaches.” (Fowers, Wagner (1997))
In the opinion of the student, who herself comes from a multi-cultural and multi-denominational family of
origin, from the country with a long and dramatic history of social and ethnic conflicts, Böszörményi-
Nagy's Contextual Approach casts a new light on fluctuations of family and individual goals, “split
loyalties” and legacies of “created realities,” passed down through generations.
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Narrative Family Therapy
From Wikipedia, the free encyclopedia
Narrative Therapy is a form of psychotherapy using narrative. It was initially developed during the 1970s
and 1980s, largely by Australian Michael White and his friend and colleague, David Epston, of New
Zealand.
Their approach became prevalent in North America with the 1990 publication of their book, Narrative
Means to Therapeutic Ends, followed by numerous books and articles about previously unmanageable cases
of anorexia nervosa, ADHD, schizophrenia, and many other problems. In 2007 White published Maps of
Narrative Practice, a presentation of six kinds of key conversations.
Contents
1 Overview
2 Narrative therapy topics
o 2.1 Concept
o 2.2 Narrative approaches
o 2.3 Common elements
o 2.4 Method
o 2.5 Outsider Witnesses
3 Criticisms of Narrative Therapy
4 See also
5 References
6 External links
Overview
The term "narrative therapy" has a specific meaning and is not the same as narrative psychology, or any
other therapy that uses stories. Narrative therapy refers to the ideas and practices of Michael White, David
Epston, and other practitioners who have built upon this work. The narrative therapist focuses upon
narrative and situated concepts in the therapy. The narrative therapist is a collaborator with the client in the
process of discovering richer (or "thicker") narratives that emerge from disparate descriptions of experience,
thus destabilizing the hold of negative ("thin") narratives upon the client.
By conceptualizing a non-essentialized identity, narrative practices separate persons from qualities or
attributes that are taken-for-granted essentialisms within modernist and structuralist paradigms. This process
of externalization allows people to consider their relationships with problems, thus the narrative motto: “The
person is not the problem, the problem is the problem.” So-called strengths or positive attributes are also
externalized, allowing people to engage in the construction and performance of preferred identities.
Operationally, narrative therapy involves a process of deconstruction and "meaning making" which are
achieved through questioning and collaboration with the client. While narrative work is typically located
within the field of family therapy, many authors and practitioners report using these ideas and practices in
community work, schools and higher education.
Although narrative therapists may work somewhat differently (for example, Epston uses letters and other
documents with his clients, though this particular practice is not essential to narrative therapy), there are
several common elements that might lead one to decide that a therapist is working "narratively" with clients.
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Narrative therapy topics
Concept
Narrative therapy holds that our identities are shaped by the accounts of our lives found in our stories or
narratives. A narrative therapist is interested in helping others fully describe their rich stories and
trajectories, modes of living, and possibilities associated with them. At the same time, this therapist is
interested in co-investigating a problem's many influences, including on the person himself and on their
chief relationships.
By focusing on problems' effects on people's lives rather than on problems as inside or part of people,
distance is created. This externalization or objectification of a problem makes it easier to investigate and
evaluate the problem's influences.
Another sort of externalization is likewise possible when people reflect upon and connect with their
intentions, values, hopes, and commitments. Once values and hopes have been located in specific life
events, they help to “re-author” or “re-story” a person's experience and clearly stand as acts of resistance to
problems.
The term “narrative” reflects the multi-storied nature of our identities and related meanings. In particular,
re-authoring conversations about values and re-membering conversations about key influential people are
powerful ways for people to reclaim their lives from problems. In the end, narrative conversations help
people clarify for themselves an alternate direction in life to that of the problem, one that comprises a
person's values, hopes, and life commitments.
Narrative approaches
Briefly, narrative approaches hold that identity is chiefly shaped by narratives or stories, whether uniquely
personal or culturally general. Identity conclusions and performances that are problematic for individuals or
groups signify the dominance of a problem-saturated story.
Problem-saturated stories gain their dominance at the expense of preferred, alternative stories that often are
located in marginalized discourses. These marginalized knowledges and identity performances are
disqualified or invisibilized by discourses that have gained hegemonic prominence through their acceptance
as guiding cultural narratives. Examples of these subjugating narratives include capitalism;
psychiatry/psychology; patriarchy; heterosexism; and Eurocentricity.
Furthermore, binaries such as healthy/unhealthy; normal/abnormal; and functional/dysfunctional ignore
both the complexities of peoples’ lived experiences as well as the personal and cultural meanings that may
be ascribed to their experiences in context.
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Common elements
Common elements in narrative therapy are:
The assumption that narratives or stories shape a person's identity, as when a person assesses a
problem in their life for its effects and influences as a "dominant story";
An appreciation for the creation and use of documents, as when a person and a counsellor co-author
"A Graduation from the Blues Certificate";
An "externalizing" emphasis, such as by naming a problem so that a person can assess its effects in
her life, come to know how it operates or works in her life, relate its earliest history, evaluate it to
take a definite position on its presence, and in the end choose their relationship to it.
A focus on "unique outcomes" (a term of Erving Goffman) or exceptions to the problem that
wouldn't be predicted by the problem's narrative or story itself.
A strong awareness of the impact of power relations in therapeutic conversations, with a
commitment to checking back with the client about the effects of therapeutic styles in order to
mitigate the possible negative effect of invisible assumptions or beliefs held by the therapist.
Responding to personal failure conversations
Method
In Narrative therapy a person's beliefs, skills, principles, and knowledge in the end help them regain their
life from a problem. In practice a narrative therapist helps clients examine, evaluate, and change their
relationship to a problem by acting as an “investigative reporter” who is not at the centre of the investigation
but is nonetheless influential; that is, this therapist poses questions that help people externalize a problem
and then thoroughly investigate it.
Intertwined with this problem investigation is the uncovering of unique outcomes or exceptions to its
influences, exceptions that lead to rich accounts of key values and hopes—in short, a platform of values and
principles that provide support during problem influences and later an alternate direction in life.
The narrative therapist, as an investigative reporter, has many options for questions and conversations
during a person's effort to regain their life from a problem. These questions might examine how exactly the
problem has managed to influence that person's life, including its voice and techniques to make itself
stronger.
On the other hand, these questions might help restore exceptions to the problem's influences that lead to
naming an alternate direction in life. Here the narrative therapist relies on the premise that, though a
problem may be prevalent and even severe, it has not yet completely destroyed the person. So, there always
remains some space for questions about a person's resilient values and related, nearly forgotten events. To
help retrieve these events, the narrative therapist may begin a related re-membering conversation about the
people who have contributed new knowledges or skills and the difference that has made to someone and
vice-versa for the remembered, influential person.
Outsider Witnesses
In this particular narrative practice or conversation, outsider witnesses are invited listeners to a consultation.
Often they are friends of the consulting person or past clients of the therapist who have their own
knowledge and experience of the problem at hand. During the first interview, between therapist and
consulting person, the outsider listens without comment.
Then the therapist interviews them with the instructions not to critique or evaluate or make a proclamation
about what they have just heard, but instead to simply say what phrase or image stood out for them,
followed by any resonances between their life struggles and those just witnessed. Lastly, the outsider is
asked in what ways they may feel a shift in how they experience themselves from when they first entered
the room [8]
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Next, in similar fashion, the therapist turns to the consulting person, who has been listening all the while,
and interviews them about what images or phrases stood out in the conversation just heard and what
resonances have struck a chord within them.
In the end, an outsider witness conversation is often rewarding for witnesses. But for the consulting person
the outcomes are remarkable: they learn they are not the only one with this problem, and they acquire new
images and knowledge about it and their chosen alternate direction in life. The main aim of the narrative
therapy is to engage in people's problems by providing the alternative best solution.
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DEFINITIONS
The identified patient
The identified patient (IP) is the family member with the symptom that has brought the family into
treatment. Children and adolescents are frequently the IP in family therapy. The concept of the IP is used by
family therapists to keep the family from scapegoating the IP or using him or her as a way of avoiding
problems in the rest of the system.
Homeostasis (Balance)
Homeostasis means that the family system seeks to maintain its customary organization and functioning
over time, and it tends to resist change. The family therapist can use the concept of homeostasis to explain
why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and
what is likely to happen when the family begins to change.
The extended family field.
The extended family field includes the immediate family and the network of grandparents and other
relatives of the family. This concept is used to explain the intergenerational transmission of attitudes,
problems, behaviours, and other issues. Children and adolescents often benefit from family therapy that
includes the extended family.
Differentiation
Differentiation refers to the ability of each family member to maintain his or her own sense of self, while
remaining emotionally connected to the family. One mark of a healthy family is its capacity to allow
members to differentiate, while family members still feel that they are members in good standing of the
family.
Triangular relationships
Family systems theory maintains that emotional relationships in families are usually triangular. Whenever
two members in the family system have problems with each other, they will "triangle in" a third member as
a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that
maintains family homeostasis. Common family triangles include a child and his or her parents; two children
and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.
Multisystemic Therapy
In the early 2000s, a new systems theory, multisystemic therapy (MST), has been applied to family therapy
and is practiced most often in a home-based setting for families of children and adolescents with serious
emotional disturbances. MST is frequently referred to as a "family-ecological systems approach" because it
views the family's ecology, consisting of the various systems with which the family and child interact (for
example, home, school, and community). Several clinical studies have shown that MST has improved
family relations, decreased adolescent psychiatric symptoms and substance use, increased school
attendance, and decreased re-arrest rates for adolescents in trouble with the law. In addition, MST can
reduce out-of-home placement of disturbed adolescents.
Calibration:
Setting of a range limit (bias) in a system, like a thermostat in a room. The limit of how much change a
family will tolerate. (Bias: a family's emotional thermostat. The therapist needs to look into who has the
power to reset it.)
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Family Life Cycle:
Just like an individual, a family has developmental tasks and key (second-order) transitions like leaving
home, joining of families through marriage, families with young children (the key milestone, and one that
initiates vertical realignment), families with adolescents, launching children and moving on, families in later
life. Key question: "How well did the family do on its last assignment?" Horizontal stressors are those
involving these transitional assignments; vertical stressors are transmitted mainly via multigenerational
triangling. Symptoms tend to occur when horizontal and vertical stressors intersect. Divorce adds extra
developmental steps for all involved families.
Centrifugal/centripetal:
Tendency of family members to move toward or away from a family.
Circular (mutual, reciprocal) causality:
When things cause each other rather than just one causing the other (linear causality). Emphasizes present,
process over past, content.
Open/Closed systems:
Open: Those that embrace new information and display negentropy (growth).
Closed: Those unfriendly to new information; they tend to have a lot of entropy.
Cybernetics:
Norbert Weiner (1948) used this term to describe systems that self-regulate via feedback loops.
Feedback loops: information pathways that help the system balance and correct itself. Can be negative
(maintains the current bias and level of functioning) or positive (changes the bias/level of functioning).
Double bind
(Bateson, Jackson, Haley, Weakland): when the content and process of a message don't line up and you're
not allowed to comment on that.
No-talk rule: an unwritten family rule against members commenting on certain uncomfortable issues.
Three kinds of therapeutic double-binds or paradoxes: prescribing, restraining ("don't change") , and
positioning (exaggerate negative interpretations of the situation).
Equifinality / Equipotentiality:
Equifinality: things with dissimilar origins can wind up in similar places (e.g., an abuse survivor and
someone from a healthy family can both grow up to be good parents).
Equipotentiality: things with a common origin can go in very different directions of development (e.g., of
two abuse survivors, one heals and the other becomes a criminal).
First-order / Second-order change:
First-order change: change that helps the system accommodate to its current level of functioning.
Second-order change: a change that fundamentally impacts the system, thereby taking it to a new level of
functioning.
Pseudo mutuality:
Wynne, Lyman: noticed that many families exhibit pseudo mutuality (fake togetherness).
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Punctuation:
“The selective description of a transaction in accordance with a therapist’s goals”. Therefore, it is
verbalizing appropriate behaviour when it happens.
Rules:
Expectations that govern the system on many levels. Can be covert or overt. Good rules maintain stability
while allowing some adaptive changes; rigid ones block even modest attempts to adapt. A therapeutic task is
to make the covert rules overt.
Criticisms of Narrative Therapy
To date, there have been several formal criticisms of Narrative Therapy over what are viewed as its
theoretical and methodological inconsistencies, among various other concerns.
Narrative therapy has been criticised as holding to a social constructionist belief that there are no
absolute truths, but only socially sanctioned points of view, and that Narrative therapists therefore
privilege their client's concerns over and above "dominating" cultural narratives.
Several critics have posed concerns that Narrative Therapy has made gurus of its leaders,
particularly in the light that its leading proponents tend to be overly harsh about most other kinds of
therapy. Others have criticized Narrative Therapy for failing to acknowledge that the individual
Narrative therapist may bring personal opinions and biases into the therapy session.
Narrative therapy is also criticized for the lack of clinical and empirical studies to validate its many
claims. Etchison & Kleist (2000) state that Narrative Therapy's focus on qualitative outcomes is not
congruent with larger quantitative research and findings which the majority of respected empirical
studies employ today. This has led to a lack of research material which can support its claims of
efficacy.
See also
Theoretical foundations
Constructivist epistemology
Feminism
Hermeneutics
Postmodernism
Poststructuralism
Related types of therapy
Brief therapy
References
Family therapy
Response based therapy
Solution focused brief therapy
Other related concepts
Dialogical self
Lucid dream
Questioning
1. White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: WW Norton.
2. White, M. (2007). Maps of narrative practice. NY: W.W. Norton.
3. Dulwich Centre, 1997, 2000
4. Winslade, John & Monk, Gerald. (2000) Narrative Mediation: A New Approach to Conflict
Resolution. San Francisco: Jossey-Bass. ISBN 0-7879-4192-1
5. (Lewis & Chesire, 1998)
6. (Nylund and Tilsen, 2006).
7. Narrative Means to Therapeutic Ends; Maps of Narrative Practice; White, M. (2000). Reflections on
Narrative Practice Adelaide, South Australia: Dulwich Centre Publications
8. White, M. (2005). Narrative practice and exotic lives: Resurrecting diversity in everyday life.
Adelaide: Dulwich Centre Publications. pp 15.
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9. Fish, V., Post Structuralism in Family Therapy: Interrogating the Narrative/Conversational Mode.
Journal of Family Therapy 19(3) 221-232 (1993)
10. Minuchin, S., Where is the Family in Narrative Family Therapy? Journal of Marital and Family
Therapy, 24(4), 397-403 (1998)
We do not tell stories only: we are stories.
Storytelling is now emerging as a critical component of Scottsdale family therapy. There are now quite a
number of Scottsdale therapists who have gained positive results in their sessions with individuals facing
varied family issues. It is essential that we spend some time and understand some important principles that
come into play when storytelling is adopted as a major element of the family therapy approach.
Storytelling as a major element of family therapy relays ideas and messages holistically. As a result to this,
the listeners are able to receive the message in a simple, logical manner and in one single flow.
Storytelling is considered as an age-old form of expressing ideas and emotions. This type of communication
is the native language which can be used with persons as young as two years of age. On the other hand, the
abstract form of communication becomes effective only to individuals who are at least 8 years old.
This method of communication allows the family therapist to communicate in a way that allows him to sort
out the elements in logical sequence out from a chaotic setting. This approach connects the individual to
time and space, and the direction of the sequence of events becomes clearer enabling the therapist to deliver
a more sensible idea or message. Family therapists are able to deliver holistic realities once they adopt
storytelling as an integral part of the therapy sessions as opposed to abstract method of communication
which normally breaks down the message into fragments.
Abstract type of communication forces on our perceived time and space and sets its own framework and
applies such mental framework to another individual. What happens to such type of therapy is that the
person is limited to just two options- accepting or rejecting the idea relayed by the family therapist. With the
abstract communication approach, one ends up with a yes-no, all or nothing type of confrontation. By
contrast, storytelling comes out as a collaborative encounter which encourages the listener to participate in
an arm-in-arm activity with the family therapist. This narrative element of family therapy is more of a
rhythmic dance rather than a communication struggle.
What makes this narrative approach a truly effective adjunct of the entire family therapy procedure is that it
allows the listener create a parallel event in his own consciousness. This increases the possibility of
acceptance more than the rejection that we normally experience in the abstract type of communication.
Another critical aspect of storytelling has something to do with tacit knowledge. We know more things than
we actually believe we have and it is important to acknowledge the importance of tacit knowledge in the
overall scheme of things.
Finally, abstract type of communication is in general described as dry and dull because individuals struggle
to relate it to reality. As living creatures with unique characteristics we are easily attached to things that are
animate and reject inert and inanimate things like abstracted concepts. Individuals always consider the
experience of storytelling as lively and entertaining. It is one great way we can accept ideas as it is
presented explicitly by a competent family therapist.
White, Michael: people's lives are organized by their life narratives. We become the stories we tell about
our own experience. Replace unhelpful stories with helpful ones.
(Article Source: http://EzineArticles.com/2428390)
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Basic Techniques in Family Therapy
The area of marriage and family counselling/therapy has exploded over the past decade. Counsellors at all
levels are expected to work effectively with couples and families experiencing a wide variety of issues and
problems. Structural, strategic, and trans-generational family therapists at times may seem to be operating
alike, using similar interventions with a family. Differences might become clear when the therapist explains
a certain technique or intervention. Most of today's practicing family therapists go far beyond the limited
number of techniques usually associated with a single theory.
Bowen therapists believe that understanding how a family system operates is far more important than using
a particular technique. They tend to use interventions such as process questions, tracking sequences,
teaching, coaching, and directives with a family. They value information about past relationships as a
significant context from which they design interventions in the present.
The following select techniques have been used in working with couples and families to stimulate change or
gain greater information about the family system. Each technique should be judiciously applied and viewed
as not a cure, but rather a method to help mobilize the family. The when, where, and how of each
intervention always rests with the therapist's professional judgment and personal skills.
OBSERVATION
Family units establish equilibriums to protect the family unit, but that equilibrium can cause an imbalance
for individual parts of the family. A clinical psychologist is trained to observed the family dynamic and
monitor both verbal and non-verbal cues. During the assessment phase and initial interviews, the family
systems psychologist will monitor how the parents interact with each other and how their children react to
them. He or she will compare his or her observations with testing data offered in both subjective and
objective forms. The subjective test data is gathered during the interview while the objective test data is
gathered via clinical tests that family members are requested to fill out and return to the psychologist.
Observation is an effective family therapy technique because it offers the psychologist the first real window
into the family dynamic. Family therapy may be recommended for any number of causes, but for the
psychologist to make a fair and accurate assessment, he or she must get a base measurement of the family's
interactions, emotional balance and initial dysfunction. During observation, for example, it may be revealed
that a mother's depression and need for anti-anxiety medication is due in part to her husband's
unemployment and the economic pressure she is overcompensating to fulfill. To create an effective
treatment plan for the family, the therapist needs as much data as possible.
IDENTIFICATION
Family therapy techniques are used with individuals and families to address the issues that effect the health
of the family system. The techniques used will depend on what issues are causing the most problems for a
family and on how well the family has learned to handle these issues.
Strategic techniques are designed for specific purposes within the treatment process. Background
information, family structuring and communication patterns are some of the areas addressed through these
methods.
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I/ INFORMATION-GATHERING TECHNIQUES
At the start of therapy, information regarding the family's background and relationship dynamics is needed
to identify potential issues and problems.
GETTING INFORMATION THROUGH USING OPEN-ENDED QUESTIONS.
An open-ended question cannot be answered with a simple "yes" or "no", or with a specific piece of
information, and gives the person answering the question scope to give the information that seems to them
to be appropriate. Open-ended questions are sometimes phrased as a statement which requires a response.
Examples of open-ended questions:
Tell me about your relationship with your husband.
How do you see your future?
Tell me about the children in this photograph.
What is the purpose of this rule?
Why did you choose that answer?
THE GENOGRAM
Is an information gathering technique used to create a family history, or geneology. The genogram reveals
the family's basic structure and demographics.
The genogram, is a technique that is often used early in family therapy, provides a graphic picture of the
family history. As an informational and diagnostic tool, the genogram is developed by the therapist in
conjunction with the family.
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Bowen assumes that multigenerational patterns and influences are central in understanding present nuclear
family functioning. A family genogram consists of a pictorial layout of each partner's three-generational
extended family. It is a tool for both the therapist and family members to understand critical turning points
in the family's emotional processes and to note dates of births, deaths, marriages, and divorces.
The genogram also includes additional information about essential characteristics of a family: cultural and
ethnic origins, religious affiliation, socioeconomic status, type of contact among family members, and
proximity of family members. Names, dates of marriage, divorce, death, and other relevant facts are also
included. Siblings are presented in genograms horizontally, oldest to youngest, each with more of a
relationship to the parents than to one another. Bowen also integrates data related to birth order and family
constellation. By providing an evolutionary picture of the nuclear family, a genogram becomes a tool for
assessing each partner's degree of fusion to extended families and to each other.
THE FAMILY FLOORPLAN
By having family members draw up floor plans of their home, they provide information on territorial issues,
rules, and comfort zones between different members.
The family floor plan technique has several variations. Parents might be asked to draw the family floor plan
for the family of origin. Information across generations is therefore gathered in a nonthreatening manner.
Points of discussion bring out meaningful issues related to one's past.
Another adaptation of this technique is to have members draw the floor plan for their nuclear family. The
importance of space and territory is often inferred as a result of the family floor plan. Levels of comfort
between family members, space accommodations, and rules are often revealed. Indications of
differentiation, operating family triangles, and subsystems often become evident. Used early in therapy, this
technique can serve as an excellent diagnostic tool (Coppersmith, 1980).
FAMILY PHOTOS
Is an information gathering technique which has the potential to provide a wealth of information about past
and present functioning and about how each member perceives the others.
One use of family photos is to go through the family album together. Verbal and nonverbal responses to
pictures and events are often quite revealing. Adaptations of this method include asking members to bring in
significant family photos and discuss reasons for bringing them, and locating pictures that represent past
generations. Through discussion of photos, the therapist often more clearly sees family relationships, rituals,
structure, roles, and communication patterns.
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II/ JOINING
This is the process of coupling that occurs between the therapist and the family, leading to the development
of therapeutic system. In this process the therapist allies with family members by expressing interest in
understanding them as individuals and working with and for them. Joining is considered one of the most
important prerequisites to restructuring. It is a contextual process that is continuous. There are four ways of
joining in structural family therapy: tracking, mimesis, confirmation of a family member and accomodation.
1) TRACKING:
The tracking technique is a recording process where the therapist keeps notes on how situations develop
within the family system. Interventions used to address family problems can be designed based on the
patterns uncovered by this technique. In tracking, the therapist follows the content of the family that is the
facts. Tracking is best exemplified when the therapist gives a family feedback on what he or she has
observed or heard.
Most family therapists use tracking. Structural family therapists (Minuchin & Fishman, 1981) see tracking
as an essential part of the therapist's joining process with the family. During the tracking process the
therapist listens intently to family stories and carefully records events and their sequence. Through tracking,
the family therapist is able to identify the sequence of events operating in a system to keep it the way it is.
What happens between point A and point B or C to create D can be helpful when designing interventions.
2) MIMESIS:
The therapist becomes like the family in the manner or content of their communications.
3) CONFIRMATION OF A FAMILY MEMBER:
Using an affective word to reflect an expressed or unexpressed feeling of that family member.
4) ACCOMMODATION:
The therapist adapts to a family's communication style. He makes personal adjustments in order to achieve a
therapeutic alliance.
III/ DIAGNOSING
Diagnosing is done early in the therapeutic process. The goal is to describe the systematic interrelationships
of all family members to see what needs to be changed or modified for the family to improve. By
diagnosing interactions, therapists become proactive, instead of reactive.
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IV/ FAMILY SYSTEM STRATEGIES
A family operates like a system in that each member's role contributes to the patterns of behaviour that
make the system what it is. Certain therapy techniques are designed to reveal the patterns that make a family
function the way it does.
ASKING PROCESS QUESTIONS.
The most common Bowen technique consists of asking process questions that are designed to get clients to
think about the role they play in relating with members of their family. Bowen's style tended to be
controlled, somewhat detached, and cerebral. In working with a couple, for example, he expected each
partner to talk to him rather than to talk directly to each other in the session. His calm style of questioning
was aimed at helping each partner think about particular issues that are problematic with their family of
origin. One goal is to resolve the fusion that may exist between the partners and to maximize each person's
self-differentiation both from the family of origin and the nuclear family system.
A Bowen therapist is more concerned with managing his or her own neutrality than with having the "right"
question at the right time. Still, questions that emphasize personal choice are very important. They calm
emotional response and invite a rational consideration of alternatives. A therapist attempting to help a
woman who has been divorced by her husband may ask:
"Do you want to continue to react to him in ways that keep the conflict going, or would you rather feel
more in charge of your life?"
"What other ways could you consider responding if the present way isn't very satisfying to you and is
not changing him?"
"Given what has happened recently, how do you want to react when you're with your children and the
subject of their father comes up?"
Notice that these process questions are asked of the person as part of a relational unit. This type of
questioning is called circular, or is said to have circularity, because the focus of change is in relation to
others who are recognized as having an effect on the person's functioning.
FAMILY SCULPTING
Family sculpting is a technique that's used to realign relationship patterns within the group. Members are
asked to physically arrange where they want each member to be in relation to the others. This technique
provides insight into relationship conflicts within the family. Family sculpting provides for recreation of the
family system, representing family members relationships to one another at a specific period of time. The
family therapist can use sculpting at any time in therapy by asking family members to physically arrange the
family. Adolescents often make good family sculptors as they are provided with a chance to nonverbally
communicate thoughts and feelings about the family. Family sculpting is a sound diagnostic tool and
provides the opportunity for future therapeutic interventions.
FAMILY CHOREOGRAPHY
In family choreography, arrangements go beyond initial sculpting; family members are asked to position
themselves as to how they see the family and then to show how they would like the family situation to be.
Family members may be asked to re-enact a family scene and possibly re-sculpt it to a preferred scenario.
This technique can help a stuck family and create a lively situation.
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V/ INTERVENTION TECHNIQUES
Intervention techniques are directives given by the therapist to guide a family's interactions towards more
productive outcomes. Reframing is a method used to recast a particular conflict or situation in a less
threatening light. A father who constantly pressures his son regarding his grades may be seen as a
threatening figure by the son. Reframing this conflict would involve focusing on the father's concern for his
son's future and helping the son to "hear" his father's concern instead of constant demands for improvement.
Another technique has the therapist placing a particular conflict or situation under the family's control. What
this means is, instead of a problem controlling how the family acts, the family controls how the problem is
handled. This requires the therapist to give specific directives as to how long members are to discuss the
problem, who they discuss it with, and how long these discussions should last. As members carry out these
directives, they begin to develop a sense of control over the problem, which helps them to better deal with it
effectively.
RELATIONSHIP EXPERIMENTS.
“Relationship experiments are behavioural tasks assigned to family members by the therapist to first expose
and then alter the dysfunctional relationship process in the family system” (Guerin, 2002, p. 140). Most
often, these experiments are assigned as homework, and they are commonly designed to reverse pursuerdistancer
relationships and/or address the issues related to triangulation.
DETRIANGULATION
Relationship experiments are incorporated within Guerin’s five-step process for neutralization of
symptomatic triangles in which he
(1) identifies the triangle,
(2) delineates the triangle’s structure and movement,
(3) reverses the direction of the movement,
(4) exposes the emotional process, and
(5) addresses the emotional process to augment family functionality.
COACHING.
Bowen used coaching with well-motivated family members who had achieved a reasonable degree of selfdifferentiation.
To coach is to help people identify triggers to emotional reactivity, look for alternative
responses, and anticipate desired outcomes. Coaching is supportive, but is not a rubber-stamp: It seeks to
build individual independence, encouraging confidence, courage, and emotional skill in the person.
I-POSITIONS.
I-positions are clear and concise statements of personal opinion and belief that are offered without
emotional reactivity. When stress, tension, and emotional reactions increase, I-positions help individual
family members to step-back from the experience and communicate from a more centred, rational, and
stabilized position. Bowen therapists model I-positions within sessions when family members become
emotionally reactive, and as family members are able to take charge of their emotions, Bowen therapists
also coach them in the use of I-statements.
DISPLACEMENT STORIES.
Displacement stories are usually implemented through the use of film or videotape, although storytelling
and fantasized solutions have also been used. The function of a displacement story is to provide a family or
family members with an external stimulus (film, video, book or story) that relates to the emotional process
and triangulation present in the family, but allows them to be considered in a less defensive or reactive
manner. Films, like “I Never Sang For My Father,” “Ordinary People,” or “Avalon” have all been used by
Bowen therapists to highlight family interactions and consequences and to suggest resolutions of a more
functional nature.
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TAKING SIDE & MEDIATING.
In contrast to Bowen's belief in the importance of neutrality, another influential family therapist, Zuk (1981)
discusses practical applications of working with triangles in family therapy. Zuk terms his triadic-based
technique go-between process because it relies on the therapists "taking and trading roles... of the mediator
and side-taker". The mediator is one person mediating between at least two others. The side-taker joins one
person in coalition against another.
Zuk (1981) outlines three steps involved in the go-between process (p. 38).
In step 1, the therapist works on initiating conflict.
In step 2, the therapists moves into the role of the go-between.
In step 3, the therapist assumes the role of side-taker.
In all three steps it is important to keep the interactions focused on the present. Past events preclude the
therapist's involvement in mediating or side-taking.
Because triangles constantly move around, the current permutation might be different from the past. The
goal of the therapist is to change the pathogenic relating around into a more productive way of relating.
THE EMPTY CHAIR
The empty chair technique, most often utilized by Gestalt therapists (Perls, Hefferline, & Goodman, 1985),
has been adapted to family therapy. In one scenario, a partner may express his or her feelings to a spouse
(empty chair), then play the role of the spouse and carry on a dialogue. Expressions to absent family,
parents, and children can be arranged through utilizing this technique.
FAMILY COUNCIL MEETINGS
Family council meetings are organized to provide specific times for the family to meet and share with one
another. The therapist might prescribe council meetings as homework, in which case a time is set and rules
are outlined. The council should encompass the entire family, and any absent members would have to abide
by decisions. The agenda may include any concerns of the family. Attacking others during this time is not
acceptable. Family council meetings help provide structure for the family, encourage full family
participation, and facilitate communication.
STRATEGIC ALLIANCES
This technique, often used by strategic family therapists, involves meeting with one member of the family
as a supportive means of helping that person change. Individual change is expected to affect the entire
family system. The individual is often asked to behave or respond in a different manner. This technique
attempts to disrupt a circular system or behaviour pattern.
PRESCRIBING INDECISION
The stress level of couples and families often is exacerbated by a faulty decision-making process. Decisions
not made in these cases become problematic in themselves. When straightforward interventions fail,
paradoxical interventions often can produce change or relieve symptoms of stress. Such is the case with
prescribing indecision. The indecisive behaviour is reframed as an example of caring or taking appropriate
time on important matters affecting the family. A directive is given to not rush into anything or make hasty
decisions. The couple is to follow this directive to the letter.
PUTTING THE CLIENT IN CONTROL OF THE SYMPTOM
This technique, widely used by strategic family therapists, attempts to place control in the hands of the
individual or system. The therapist may recommend, for example, the continuation of a symptom such as
anxiety or worry. Specific directives are given as to when, where, and with whom, and for what amount of
time one should do these things. As the client follows this paradoxical directive, a sense of control over the
symptom often develops, resulting in subsequent change.
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SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS
Couples and families that are stuck frequently exhibit predictable behaviour cycles. Boredom is present, and
family members take little time with each other. In such cases, family members feel unappreciated and
taken for granted. "Caring Days" can be set aside when couples are asked to show caring for each other.
Specific times for caring can be arranged with certain actions in mind (Stuart, 1980).
PROBLEM SOLVING
Problem solving is an effective therapy technique not because it teaches the family how to resolve the issue
that brought them to see the family systems psychologist, but it teaches them how to identify, develop plans
and create resolutions for future problems. Problem solving may seem like a common sense resolution, but
it requires a willingness on the parts of all parties to contribute to the solution.
Problem solving is a family therapy technique that requires effective communication and often comes later
in therapy sessions as the therapist challenges family members to role-play situations previously deemed
irresolvable. Family members may also be required to play the part of other family members, parents
playing the part of the children or dad taking on the role of mom to a child's dad and a mom's child. By
actively role playing other members of the family, each member is required to see that person's point of
view. This leads to learning how to disagree in positive and respectful manner and to not allow those
disagreements to impede problem solving efforts.
FAMILY CONTRACTS
The family contract is a therapeutic tool that allows families to negotiate terms and come to an agreement
on how they want to handle future family problems and to commit to positive change. A family contract, for
example, may detail that a child who copes with an eating disorder commits to talking about her feelings on
weight, eating and social perception. Her parents will then commit to listening and not dismissing her
feelings. All parties commit to working together to build self-esteem and a healthy lifestyle.
Family contracts are a positive tool in the arsenal of a family systems psychologist because they are
facilitated agreement that a family makes to avoid future dysfunction. The family contract also helps family
members recognize when problems are occurring, particularly if elements of the contract are not being
upheld. Effective family therapy techniques treat the entire family as an emotional unit of which each family
member is a part of and acknowledges that what affects one member of the family affects the whole family.
By treating the whole family as a unit, the family also becomes a part of the solution.
REFRAMING
Technique used to create a different perception of reality. Reframing is a process in which a perception is
changed by explaining a situation in terms of a different context. For example, the therapist can reframe a
disruptive behaviour as being naughty instead of incorrigible allowing family members to modify their
attitudes toward the individual and even help him or her makes changes.
Most family therapists use reframing as a method to both join with the family and offer a different
perspective on presenting problems. Specifically, reframing involves taking something out of its logical
class and placing it in another category (Sherman & Fredman, 1986). For example, a mother's repeated
questioning of her daughter's behaviour after a date can be seen as genuine caring and concern rather than
that of a non trusting parent. Through reframing, a negative often can be reframed into a positive.
Reframing is altering the meaning or value of something, by altering its context or description
Reframing is a powerful change stratagem. It changes our perceptions, and this may then affect our actions.
But does changing our symbolic representation of the real world actually change anything in the real world
itself?
Kolb describes the four basic creative dimensions as Meaning, Value, Relevance and Fact. This is
summarized in the diagram above. In these terms, reframing is altering Meaning, Value, Relevance or Fact
by altering context or perspective.
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Bandler & Grinder (NLP) identify two forms of reframing: meaning and context. Context reframing takes
an undesired attribute and finds a different situation where it would be valuable. In meaning reframing, you
take an undesired attribute and find a description where the attribute takes on a positive value.
Reframing - Virginia Satir
A classic example of a reframe by Virginia Satir concerns a father who complains at the stubbornness of his
daughter. This results in a double reframe, in which Satir points out two things to the father:
1. There are situations where she will need stubbornness, to protect herself or achieve something.
Reframing switches to a context that makes the stubbornness relevant.
2. It is from the father himself that she has learned to be stubborn. By forcing the father to equate his
own stubbornness with hers, this creates a context in which he either has to recognize the value of her
stubbornness, or deny the value of his own.
Reframing - Milton Erikson
One of the common challenges of family therapy is to help the parents to let their children go. Independence
is of course a negative goal. The parents have to gradually stop supporting their children, and the children
have to gradually stop relying on their parents.
Milton Erikson often used the approach of creating an alternative goal for the parents: of preparing
themselves to be grandparents. In a typical case, a young woman consulted him; her parents had used their
life savings to build an extension to their house, where she was to live, when she got married (At this time,
she was away at college, and had no steady boyfriend.) Erikson met the parents, and congratulated them for
their willingness to participate so actively in the rearing of their (hypothetical) grandchildren, having babies
crying through the night, toddlers crawling through the living rooms, toys strewn across the house,
babysitting. He thus created a powerful positive image of the joys of grandparenthood; yet for some reason,
the couple decided to rent the extra rooms out to mature lodgers instead, and save the money to support their
grandchildren’s education. When the daughter subsequently got married, she lived in a city some distance
away with husband and baby, and the grandparents visited frequently, but not too frequently.
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PUNCTUATION
Technique used to create a different perception of reality. Punctuation is “the selective description of a
transaction in accordance with a therapist’s goals”. Therefore it is verbalizing appropriate behaviour when
it happens.
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UNBALANCING
Technique used to create a different perception of reality. This is a procedure wherein the therapist supports
an individual or subsystem against the rest of the family. When this technique is used to support an
underdog in the family system, a chance for change within the total hierarchical relationship is fostered.
RESTRUCTURING
Technique used to create a different sequence of events. The procedure of restructuring is at the heart of the
structural approach. The goal is to make the family more functional by altering the existing hierarchy and
interaction patterns so that problems are not maintained. It is accomplished through the use of enactment,
unbalancing, and boundary formation.
ENACTMENT
Technique used to create a different sequence of events. The process of enactment consists of families
bringing problematic behavioural sequences into treatment by showing them to the therapist a demonstrative
transaction. This method is to help family members to gain control over behaviours they insist are beyond
their control. The result is that family members experience their own transactions with heightened
awareness. In examining their roles, members often adapt new, more functional ways of acting.
BOUNDARY FORMATION
Technique used to create a different sequence of events. Part of the therapeutic task is to help the family
define, or change the boundaries within the family. The therapist also helps the family to either strengthen
or loosen boundaries, depending upon the family’s situation.
WORKING WITH SPONTANEOUS INTERACTION
In addition to enactment, structural family therapists concentrate on spontaneous behaviours in sessions. It
occurs whenever families display behaviours in sessions that are disruptive or dysfunctional, such as
members yelling at one another or parents withdrawing from their children. The focus is on process not
content. It is important that therapists help families recognize patterns of interaction and what changes they
might make to bring about modification.
INTENSITY
Intensity is the structural method of changing maladaptive transactions by using strong affect, repeated
intervention, or prolonged pressure. Intensity works best if done in a direct, unapologetic manner that is goal
specific.
SHAPING COMPETENCE
The family therapists help families and individuals in becoming more functional by highlighting positive
behaviours.
ADDING COGNITIVE CONSTRUCTIONS
Advice & Information are derived from experience and knowledge of the family in therapy. They are used
to calm down anxious members of families or reassure these individuals and families about certain actions.
Pragmatic fictions are formal expressions of opinion to help families and their members change.
Paradox is an apparently sound argument leading to a contradiction. It is used to motivate family members
to search or alternatives. Family members may defy the therapists and become better or they may explore
reasons why their behaviours are as they are and make changes in the ways members interact.
Also used to tell the family what to do with the expectation of noncompliance.
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VI/ COMMUNICATION SKILL BUILDING TECHNIQUES
More often than not, it's a family's communication patterns and styles that lead to conflict and division.
Communication techniques are used to build skills that allow for effective communication between family
members.
Some of these methods include reflecting, repeating, fair fighting and nonjudgmental brainstorming.
REFLECTING
Reflecting is a listening technique which involves having a member express her feelings and concerns, then
having another member repeat back what he heard that person say.
REPEATING
Repeating is also a listening technique. It involves having a member state how he feels, while another
member repeats back what was said. Repeating and reflecting techniques allow members to better
understand where the other is coming from and why she feels as she does.
FAIR FIGHTING
Fair fighting techniques focus on attentive listening and expressing feelings and concerns in a
nonthreatening manner.
TAKING TURNS EXPRESSING FEELINGS
taking turns expressing feelings
NONJUDGMENTAL BRAINSTORMING
nonjudgmental brainstorming
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EFFECTIVE COMMUNICATION
If each member of the family is interdependent on other members of the family it stands to reason that
dysfunction with one will affect the whole. Effective communication is an important lesson that family
systems psychologist incorporate into group and individual family therapy sessions. To create an effective
solution to any dysfunction or problem in the group dynamic requires effective communication so that all
members of the group or family are in touch with each other.
For example, the mother who commits to more and more tasks in order to compensate for her family's
overextending commitments may stretch herself to the limits because she lacks the ability to communicate
how stretched thin she is. Instead, she promises to do more and more, exerting increasing emotional and
mental stress upon herself when she cannot meet all the commitments she is making. This leads to
disappointment and disagreement in the family. When other members of the family express their
disappointment, this impacts her already damaged sense of self-worth leading to a vicious cycle that may
result in depression, generalized anxiety disorder, substance abuse and more. In every way, however, the
family is not happy.
Therapists teach effective communication skills and the importance for mom to let the family know she is
overextended and that she either needs help or they need to rearrange priorities in order to break out of the
circular causality of this family's problems.
Effective communication allows a family to dialogue on their problems, concerns and feelings without
lashing out or feeling obligated to resolve the problems being shared. A large portion of effective
communication resides in active listening, a skill that must be learned.
Communication patterns and processes are often major factors in preventing healthy family functioning.
Faulty communication methods and systems are readily observed within one or two family sessions. The
family therapist constantly looks for faulty communication patterns that can disrupt the system.
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Problem - Centered Systems Family Therapy
Stages and Steps of Therapy
Assessment
Orientation
Data gathering
Problem
descriptions
Clarification and
agreement on a
problem list
Contracting
Orientation
Outlining options
Negotiating
expectations
Contract signing
A Guideline for Family Assessment
Areas Covered
1. Orientation
Their expectations
Our expectations
Rationale for seeing
the family
2. Data Gathering
a. Presenting
Problem (for each
problem)
Nature and history
of problem
Affective/emotional
components
Precipitating events
Who is involved and
how
b. General Family
Functioning:
McMaster model
dimensions
Problem solving
Roles
Communication
Affective
involvement
Affective
responsiveness
Behavior control
c. Other
Investigationsbiopsy
chosocial:
medical
d. Any other
problems?
Treatment
Orientation
Clarifying priorities
Setting tasks
Task evaluation
3. Problem List
Family's list
Doctor adds his
Closure
Orientation
Summary of
treatment
Long term goals
Follow up (optional)
4. Problem
Clarification
Obtain agreement on
list from above
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Summary of Dimension Concepts
Problem-solving
Two types of problems
instrumental and affective
Seven stages to the process
1. Identification of the
problem
2. Communication of the
problem to the appropriate
person(s)
3. Development of action
alternatives
4. Decision of one alternative
5. Action
6. Monitoring the action
7. Evaluation of success
Postulated
Most effective when all seven
stages are carried out. -
Least effective when cannot
identify problem (stop before
step 1)
Communication
Instrumental and affective
areas
Two independent dimensions
1. Clear and Direct
2. Clear and Indirect
3. Masked and Direct
4. Masked and Indirect
Postulated
Most effective: clear and
direct. - Least effective:
masked and indirect
Roles
Two family function types
-necessary and other
Two areas of family functions
-instrumental and affective
Necessary family function
groupings
A. Instrumental
1. Provision of Resources
B. Affective
1. Nurturance and Support
2. Adult Sexual
Gratification
C. Mixed
1. Life Skills Development
2. Systems Maintenance
and management
Other family functions:
-adaptive and maladaptive
Role functioning is assessed
by considering how the family
allocates responsibilities and
handles accountability for
them.
Postulated
Most effective when all
necessary family functions
have clear allocation to
reasonable individuals(s), and
accountability built in. -
Least effective when necessary
family functions are not
addressed and/or allocation
and accountability not
maintained.
Affective Responsiveness
Two groupings
-welfare emotions and
emergency emotions
Postulated
Most effective when full range
of responses are appropriate in
amount and quality to stimulus.
- Least effective when
very narrow range (one or two
affects only) and/or amount
and quality is distorted, given
the context
Affective Involvement
Six styles identified
1. Absence of involvement
2. Involvement devoid of
feelings
3. Narcissistic involvement
4. Empathic involvement
5. Over-involvement
6. Symbiotic involvement
Postulated
Most effective: empathic
involvement. - Least effective:
-symbiotic and absence of
involvement
Behavior Control
Applies to three situations
1. Dangerous situations
2. Meeting and expressing
psychobiological needs and
drives (eating, drinking,
sleeping, eliminating, sex and
aggression)
3. Interpersonal socializing
behaviour inside and outside
the family
Standard and latitude of
acceptable behavior
determined by four styles
1. Rigid
2. Flexible
3. Laissez-faire
4. Chaotic
To maintain the style, various
techniques are used and
implemented under role
functions (systems maintenance
and management)
Postulated
Most effective: flexible
behavior control. -
Least effective: chaotic
behaviour control
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Structure of a Family Therapy Session
(From an eHow Contributor )
Family communication is an evolving and complicated issue for most families. Sometimes a family therapy
session is the only place where each family member can have a voice. As children grow and marriages
evolve, the lack of communication within a family may cause issues, anger and sadness in some family
members.
Family therapy sessions help with issues like divorce, financial problems, grief, depression, stress and
substance abuse. As a counsellor, you will need to have all voices heard to find out what issues or problems
each of the family members bring to the family dynamic.
Instructions
1. Research and Background
o 1 Ask the family member who initiated the family session why he feels the family needs the
therapy.This will give you his perspective on the situation and on what is happening to the family.
o 2 Find out which family members are involved, and invite them to the sessions. Let each family
member know that the therapy will not be effective if anyone misses a session. It is best to reschedule if
one family member cannot make it to a session.
o 3 Conduct an individual and private session with each family member before commencing the family
session.
o 4 Ask all family members why they think they need a family session. Inquire if they have any issues
with the family or any individual members of the family.
o 5 Take notes on each session. Make sure you write down each family member's thoughts and concerns
for future reference.
o 6 Recommend individual counseling for those members who have problems stemming from trauma or
childhood problems. They will continue to bring their issues to the family dynamic, so it is critical to
resolve their issues to help the family unite.
2. Family Session
o 1 Review your notes from each session you had with individual family members. This will refresh your
memory and let you understand more background information before you conduct your family session.
o 2 Set rules for the family therapy session. Ask members to contribute to how the session will be
conducted. Some members may insist on having one person at a time speak, or perhaps there may be a
time limit set for each person. Let each person contribute.
o 3 Begin by asking each member what kind of family dynamic they prefer. You can ask them if they
prefer a family that is close, laughs a great deal and takes fun-filled family vacations without drama.
o 4 Ensure that each member is allowed to speak without interruption. You will be acting as a mediator
on how the session is conducted. You will also be enforcing the rules the family has set in advance.
o 5 Start to resolve each individual issue that the family has brought up. Give each family member an
opportunity to provide a solution.
o 6 Apply values and standards to the solutions to the family issue that fit within that family's value
system. Devise a followup to find how the solutions are working, and invite individual family members
to contact you to ask questions.
o 7 Meet with individual family members to see if the resolution is what they expected. Inquire if they
feel problems are resolving. Some issues may be based from family disputes; others may stem from
trauma or childhood problems.
189

Read more: How to Conduct a Family Therapy Session | eHow.com
http://www.ehow.com/how_4912419_conduct-family-therapy-session.html#ixzz1J7TX2G6W
190

Structure of Family Therapy
Outline by Patty Salehpur
A. Assumptions
1. Family are individuals who effect each other in powerful but unpredicatable ways
2. The consistent repetitive organized and predictable patterns of family behavior are important
3. The emotional boundaries and coalitions are important
B. Salvador Minuchin
1. Always concerned with social issues
2. Developed a theory of family structure and guidelines to organize therapeutic techniques
3. 1970 headed Philadelphia Child Guidance Clinic where family therapists have been trained in
structural family therapy ever since
4. Born in Argentina , served in the Israel army as a physician, in the USA trained in child
psychiatry and psychoanalysis with Nathan Ackerman, worked in Israel with displaced children,
also worked in the USA with Don Jackson with middle class families.
5. Fist generation of family structural therapists: Braulio Montalvo, Jay Haley, Bernie Rosman,
Harry Aponte, Carter Umbarger, Marianne Fishman, Cloe Madanes, and Stephen Greenstein.
C. Theoretical formulations - three essential constructs
1. Structure — the organized pattern in which family members interact, predictable sequences of
family interaction, patterns of interaction. Structure involves a series of covert rules. There are
universal and idiosyncratic constraints. Families may not be able to tell you the family structure, but
they will show it to you in their interactions.
2. Subsystems — Families are differentiated into subsystems of members who join together to
perform various functions. Each person is a member of one or more subsystems in the family. Some
groupings are obvious and based on such factors as generation, gender, age or common interests.
Other coalitions may be subtle. Every member may play many roles in various subgroups.
3. Boundaries are invisible barriers that regulate the amount and nature of contact with members.
They range from rigid to diffuse, clear to unclear, disengaged to enmeshed
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D. Normal family development
1. Marriage begins with accommodation and boundary making
2. Couples are influenced by the structure of their families of origin
3. Couples also form boundaries with their families of origin
4. The advent of children requires that the structure of the family change
E. The development of behaviour disorders
1. Family dysfunction results from stress and failure to realign the structure to cope with it.
2. Disengaged families have rigid boundaries and excessive emotional distance. They fail to mobilize to
deal with the stress.
3. Enmeshed families have diffuse boundaries and family members overreact emotionally and become
intrusively involved with one another. These actions hinder mature actions to resolve stress.
4. Subsystems in the family may be disengaged or enmeshed.
5. Power hierarchies may develop which may be weak and ineffective or rigid and arbitrary.
6. Conflict avoidance prevents effective problem solving.
7. Generational coalitions may also prevent effective problem solving.
8. Family structure may fail to adjust to family developmental processes.
9. A major change in family composition demands structural adaptation.
10. Symptoms in one family member may reflect dysfunctional structural relationships or simply
individual problems.
F. Goals of therapy
1. Changing family structure - altering boundaries and realigning subsystems
2. Symptomatic change - growth of the individual while preserving the mutual support of the family
3. Short-range goals may be developed to alleviate symptoms especially in life threatening disorders
such as anorexia nervosa, but for long-lasting effective functioning the structure must change.
Behavioral techniques fit into these short-term strategies.
G. Techniques — join, map, transform structure
1. Joining and accommodating, then taking a position of leadership
a. Listen to "I" statements
2. Enactment for understanding and change
3. Working with interaction and mapping the underlying structure
a. Looking at the power hierarchies
b. Using enactment to understand and clarify
c. Looking at the boundary structures
4. Diagnosing
a. individual vs. subgroup
b. structural diagnosis
5. Highlighting and modifying interpersonal interactions is essential
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a. Control intensity by the regulation of affect, repetition and duration
b. Don’t dilute the intensity through overqualifying, apologizing or rambling
c. Shape competence, e.g. "It’s too noisy in here. Would you quiet the kids."
6. Boundary making and boundary strengthening
a. Seating
b. Seeing subgroups or individuals to foster boundaries and indivduation
c. Clarify circular causation
7. Unbalancing may be necessary
a. Taking sides
b. Challenging
c. Directives
8. Challenging the family’s assumptions may be necessary
a. Teaching may be necessary
b. Pragmatic fictions
c. Paradoxes
d. Therapist sometimes must challenge the way family members perceive reality, changing
the way family member relate to each other offers alternative views of reality.
9. Therapists must create techniques to fit each unique family
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Systemic Family Therapy Manual
Ms. Helen Pote
Dr. Peter Stratton
Prof. David Cottrell
Ms. Paula Boston
Prof. David Shapiro
Ms Helga Hanks
Leeds Family Therapy & Research Centre School of Psychology
University of Leeds
Leeds, LS2 9JT
This manual was developed through an MRC Small Project Grant,
Number G9700249
No part of this document should be reprinted without the permission of the authors.
194

INDEX
1. Introduction 186
1.1 Origins of the Manual 186
1.2 Aims and applicability of the manual 186
1.3 Notes on use of manual 187
1.4 Ethical and Culturally Sensitive Practice 188
1.5Clinical Examples 188
2. Guiding Principles 189
2.1 Systems Focus 189
2.2 Circularity 189
2.3 Connections and Patterns 189
2.4 Narratives and Language 190
2.5 Constructivism 190
2.6 Social Constructionism 190
2.7 Cultural Context 190
2.8 Power 190
2.9 Co-constructed therapy 191
2.10 Self-Reflexivity 191
2.11 Strengths and Solutions 191
3. Outline of Therapeutic Change 192
3.1 Models of Therapeutic Change 192
3.2 Overview of Specific Goals 193
4. Outline of Therapist Interventions 194
4.1 Linear Questioning 194
4.2 Circular Questions 194
4.3 Statements 195
4.4 Reflecting Teams 196
4.5 Child Centred Interventions 198
5. Therapeutic Setting 199
5.1 Convening Sessions 199
5.2 Team 199
5.3 Video 200
5.4 Pre-therapy Preparation 200
5.5 Pre and Post Session Preparation 201
5.6 Correspondence 202
5.7 Case Notes 202
195

Appendixes
Illustrations
Tables
10.7 Inattention to use of language 217
10.8 Reflections 217
10.9 Polarised position 217
10.10 Sticking in one time frame 217
10.11 Agreeing / not challenging ideas 217
10.12 Ignoring information that contradicts hypothesis 217
10.13 Dismissing ideas 218
10.14 Inappropriate affect 218
10.15 Ignoring family affect 218
10.16 Ignoring difference 218
Appendix 1: Sample Appointment Letter 219
Appendix II: Sample Video Consent Form 220
Appendix III: Sample Referrer letter 221
Appendix IV: Post-assessment letter to referrer 222
Appendix V: Closing letter to referrer 223
Figure 1: Models of Therapeutic Change
Table 1: Perceptions that are helpful in achieving change
197

1. Introduction
1.1 Origins of the Manual
The manual was developed through a research project funded by the Medical Research Council. The team
developing the manual comprised of a group of experienced family therapists working at Leeds Family
Therapy & Research Centre (LFTRC). LFTRC is a centre working systemically with individuals, couples
and families across the age span, as well as with professional systems.
The therapists contributing to this manual have historically been influenced by Milan Systemic family
therapy models, and would now describe their practice as being influenced by Post-Milan and Narrative
Models.
1.2 Aims and applicability of the manual
The manual is principally designed as a research tool for outcome studies in which the effectiveness of
systemic therapy can be assessed. It therefore aims to offer a framework and guidelines for the
implementation of systemic family therapy, so that therapists can offer a unified version of therapy, with
some flexibility to express their own creativity.
For this purpose the manual should be used in conjunction with the accompanying adherence protocol. This
is designed to assess the degree to which therapists are able to adhere to the methods outlined throughout
the manual.
For research purposes the manual is designed for use by trained family therapists or other trained therapists
with experience in family therapy. The manual’s function is to guide therapeutic work with families in a
clinic setting. Therapists using the manual will be expected to be working as part of a systemic family
therapy team. Details on the composition of therapy teams are outlined later. Section 5.2
The manual can also be used less formally as a framework for training and supervision, in developing skills
for trainee family therapists.
1.3 Notes on use of manual
As with any interpersonally focused therapy, systemic family therapy does not follow a rigidly prescribed
treatment sequence (Lambert & Ogles 1988). In using the manual therapists should consider the following
guidelines:
Therapists should first become familiar with the guiding principles which will influence all aspects of
the therapy that they carry out using this manual. They should consider the guiding principles which are
influencing them currently and the connections they make between these principles. Section 2.
They should then consider the section concerning models of change, and consider the model of change
that is influencing their own therapeutic practice.
Section 3.
After these more theoretical aspects have been addressed, the therapist should begin to consider the
general interventions used, thinking carefully about the descriptions of these interventions, and how
they may translate into their own practice. Section 4.
The manual then turns to guidelines for convening sessions, and setting up the therapy itself. Therapists
should therefore begin to follow the guidelines of the manual from the moment they take referrals, in
order to consider systemic issues in convening therapy. Section 5.
Therapists should then use the manual to more specifically guide therapy sessions, reading the practical
guidelines outlined for the beginning middle and end of therapy, and following the goals defined for
each of these stages. Therapists’ checklists are provided at the end of each of these sections to help
therapists consider whether they have covered all aspects of the guidelines.
Therapists should go on to consider the aspects of indirect work that support the family therapy which
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should still be managed following the systemic guiding principles.
Section 9.
Finally, therapists should consider the proscribed practices which should not form a significant
proportion of their work, and refer back to these during the course of therapy to ensure proscribed
practices do not emerge during the course of therapy. Section 10.
This manual has an accompanying questionnaire for therapists and an adherence protocol to assess the
degree to which therapist practice reflects that of the manual. This may be used as a personal check for
therapists or trainers using the manual, or more formally by an independent researcher to assess adherence
when the manual is being used as a research tool.
1.4 Ethical & Culturally Sensitive Practice
In using this manual therapists should pay keen attention to ensuring their practice is both ethical and
culturally sensitive. Their practice should comply with the Association for Family Therapy and Systemic
Practice (AFT): Code of Conduct and Ethical Guidelines. Therapists should remain curious and open
minded in working with families, and this may be especially important where the individuals/families are of
a different gender, cultural or societal background to that of the therapist. Care should be taken in the
assumptions and agendas therapists develop during therapy in this regard.
1.5 Clinical Examples
All of the clinical material used in this manual has been adapted from extracts of therapy undertaken at
Leeds Family Therapy & Research Centre. Identifying details have been removed from the material, and the
dialogue modified to protect confidentiality. We would like to thank all of the families and therapists who
have given permission for the therapy they undertook to be used for research. Without this permission the
research project to develop this manual would not have been possible.
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2. Guiding Principles
These principles are based at the level of theory, and should be used to guide therapists’ practice whilst
using this manual in work with families. Therapists should be familiar with all of the principles though they
may privilege different principles according to their current interests and the needs of the family with which
they are working. The therapist should consider the principles flexibly and decide which might best fit with
the issues with which the family are struggling and the therapists own current constructions. The principle
of self-reflexivity may be particular helpful in enabling the therapist to reach this. Section 2.10
In devising this manual therapists considered their own constructions of how these principles might connect.
Therapists should consider for themselves the connections they are currently making between these
principles and the effect this may have on their work with families.
2.1 Systems Focus
In working systemically the central focus should be upon the system rather than the individual, particularly
in relation to the difficulties and issues that the family system brings to therapy. The system may be A
consistent view is that these difficulties do not arise within individuals but in the relationships, interactions
and language that develop between individuals.
2.2 Circularity
Patterns of behaviour develop within systems, which are repetitive and circular in nature and also constantly
evolving. Behaviour and beliefs that are perceived as difficulties will also therefore develop in a circular
fashion, being affected by and affecting all members of the system.
2.3 Connections and Patterns
In understanding relationships and difficulties within systems it will be important for the therapist to
consider the connections between circular patterns of behaviour, and the connections between the beliefs
and behaviours within systems. The process of therapy should enable family members to consider these
connections from new and/or different perspectives.
2.4 Narratives and Language
Behaviours and beliefs form the basis of stories or narratives, which are constructed by, around, and
between individuals and the system itself. The language that is used to describe these narratives and the
interactions between individuals constructs the reality of their everyday lives. The stories that people live
often match the stories that are told about individuals, but at times when stories lived and stories told are
incongruous change may occur, at the levels of lived behaviours and/or the construction of new narratives.
2.5 Constructivism
This is the idea that people form autonomous meaning systems and will interpret and make sense of
information from this frame of reference. In social interactions understanding is constrained and affected by
this meaning system, and people cannot make assumptions about what meaning will be attributed to the
information they offer/contribute to others. Thus there is only the possibility of perturbing other people’s
meaning systems.
2.6 Social Constructionism
In working with systems in the process of change at the level of behaviour or narratives, it will be important
to consider ideas of social constructionism. Relevant is the idea that meaning is created in the social
interactions that take place between people and is thus context dependent and constantly changing, this
takes precedence over the concept of a single external reality.
2.7 Cultural Context
The therapist should consider the importance of context, in relation to the cultural meanings and narratives
within which people live their lives, including issues of race, gender, disability and class etc. The
relationship between these narratives, the therapeutic relationship and its context, as well as the wider
context for the therapeutic team and the family should be an important consideration at the point of referral
and throughout the therapy.
200

2.8 Power
The therapist should take a reflexive stance in relation to the power differentials that exist within the
therapeutic relationship, and within the family relationships.
2.9 Co-constructed therapy
In therapeutic interactions reality is co-constructed between the therapist (and team) and the people with
whom they meet. They form part of the same system, and share responsibility for change and the process of
therapy. Particular attention should thus be paid to the contributions that all members of the therapeutic
system make in the process of change.
2.10 Self-Reflexivity
The therapist should aim to apply systemic thinking to themselves and thus reject any thinking about
families and their processes that does not also apply to therapists and therapy. Self-reflexivity focuses
especially on the effect of the therapy process on the therapist and the way that this is a source of (resource
for) change in the family. In order to use self-reflexivity it will be necessary for the therapist to be alert to
their own constructions, functioning and prejudices so that they can use their self effectively with the
family.
2.11 Strengths and Solutions
The therapist should take a non-pathologising, positive view of the family system, and the current
difficulties they are struggling with. A family system that enters the therapeutic system should be
considered as a system that owns a wealth of strengths and solutions in the face of difficult situations. It is
important for the therapist to recognise that there is a multi-versa of possibilities available for each family in
the process of change, and the family themselves will be in the best position to generate suitable solutions.
The therapist can facilitate this process by attending to the strengths and solutions in the stories that the
family system brings to therapy.
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3. Outline of Therapeutic Change
3.1 Models of Therapeutic Change
In systemic work many different models of change have been hypothesised. In using this manual therapists
should consider the model of change outlined in Figure 1.
Figure 1. Model of Therapeutic Change
Cybernetics Narratives
Redundant patterns / beliefs
Understand patterns / beliefs / stories
Meaning through Langauge
Develop different patterns / beliefs / stories
Amplify change
Therapists are working with families to understand the patterns of behaviour, beliefs or stories that have
developed in family systems, and the wider context in which they live. Through the process of
understanding these behaviour patterns, beliefs or stories, therapists will begin to introduce new or different
information. Therapists may also use active strategies to introduce this new information. The information
will affect the development of behavioural patterns, beliefs and stories and the influence they have on the
family. It therefore helps the family to develop new perceptions or actions that they can use to tackle the
difficulties with which they are struggling. New perceptions that are often helpful to families in achieving
change, are outlined in Table 1. Once change is beginning to occur, therapists highlight this process to
families, enabling them to develop further changes and develop their understanding of how change was
possible. This will develop the family’s resources in coping with future struggles.
It will be important for therapists to consider the model of change with which they are currently working
and consider what aspects of this model of change they are currently privileging. What is their overall aim
during the process of therapy?
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Table 1: Perceptions that are helpful in achieving change
Initial Perception of Struggles Developing Perception of Struggles
Located in the individual Arising from the system
Uncontrollable/Unchangeable Temporary
Intrinsic Accidental
Blameworthy Redundant
Sinister Well meaning but mistaken
Linear Circular
Partisan Neutral
3.2 Overview of Specific Goals
Within each stage of therapy there are also specific goals that the therapist should be considering. The goals
are listed here and elaborated within sections 6, 7 & 8.
Goals during initial session
1. Outline Therapy Boundaries & Structure
2. Engage and Involve all family members
3. Gather and Clarify Information
4. Establish Goals and Objectives of Therapy
Goals during middle sessions
1. Develop and Monitor Engagement
2. Gather Information and Focus Discussion
3. Identify & Explore Beliefs
4. Work towards change at the level of beliefs and behaviours
5. Return to Objectives and Goals of Therapy
Goals during ending sessions
1. Gather Information and Focus Discussion
2. Continue to work towards change at the level of behaviours and beliefs
3. Develop family understanding about behaviours and beliefs
4. Secure Collaborative Decision re: Ending
5. Review the process of therapy
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4. Outline of Therapist Interventions
Therapists have a range of interventions open to them in working with the family to co-create change. The 4
interventions listed below are those which are most commonly used in systemic family therapy and should
be used in therapist’s practice throughout the course of therapy. The degree to which each of these
interventions will be used will vary throughout the course of therapy, and therapists’ should follow the
guidelines below regarding this. Additional interventions that are used less frequently are highlighted in the
appropriate stage of therapy. Sections 6, 7, & 8.
4.1 Linear Questioning
Direct linear questions can often be useful in gathering information from the system and clarifying
information given, especially at the beginning of therapy. Linear questions can be built up in a circular
manner around the family by asking different family members the same/similar linear questions.
How old are you?
Where do you go to school?
What do you do if you are upset?
What do you do after that?
4.2 Circular Questions
Linear Questions Examples
Circular questions are aimed at looking at difference and therefore are a way of introducing new
information into the system. They are effective at illuminating the interconnectedness of the family subsystems
and ideas. A variety of circular questions may be used by the therapist as outlined in Table 2. These
may be more or less appropriate as therapy progresses.
The use of particular types of circular questioning at different stages of the therapy will be highlighted
throughout the manual. The time scale of circular questions often changes fluidly between the past, present,
future.
Type of Circular Question Examples
About another’s state / behaviour /
beliefs
Circular Question Examples
What do you think John is feeling?
What do you think John is feeling when he shouts at you?
What ideas do you think John might have about that?
Offering alternative perspectives What does John think of your school performance?
If I asked a teacher what would they say about it?
About relationships - direct
- indirect
Do the girls really dislike each other?
How do the children react when they see you arguing?
Circular Definitions When you and John raise your voices and Jill starts crying what
does John do then?
About possible futures What will you think in 5 years time?
Miracle question: Imagine you woke up tomorrow morning and all
the difficulties you were experiencing currently had disappeared,
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how would things be different? What effect would that have upon
your relationship with x?
Ranking Who is most likely to get upset when father is away, and who next
is most upset?
On a scale of one to ten, how close do you think James and Sue
feel when they argue?
Though many family members will be able to answer circular questions, and think about information in a
circular manner, younger children or those with developmental difficulties, may find it cognitively
impossible to view events from another person’s perspective.
Section 4.5
4.3 Statements
Statements are used by the therapist for 3 main functions:
To clarify and acknowledge a communication from the family
To comment on the position or emotional state of a member of the family
To introduce therapist/team ideas, directly or in the form of a reflecting team. Section 4.4
In using statements therapists should ensure that they are not of long duration, and do not become therapist
monologues. Statements should also be delivered in such a manner that they are open to question or
comment from the family and not viewed as conclusive statements. Statements are sometimes used as a way
of organising information before a question is formulated to the family.
Statement Examples
So let me make sure I have understood this, you feel if you didn’t go out at all, your mum and dad
would feel reassured that you would be safe. Have I got that right?
I can see this is very upsetting, and remains an area of great distress for you. Who would be most likely
to comfort you when you are feeling like this?
You were talking a lot about trust, and about how sometimes you had struggled with developing trust as
a child, and later as an adult. How much do you feel trust is around now in your relationship with John?
4.4 Reflecting Teams
Reflecting teams aim to introduce the therapy team’s ideas into the therapy in a reflexive manner. There are
many different models for reflecting teams, and in turn these are often adapted to suit the wishes and needs
of the family in therapy. A general model for introducing and implementing reflecting teams is outlined
below.
1. Reflecting teams can be introduced during the therapy session or at the end of the session.
2. The format of the reflecting team should be negotiated with the family.
3. The reflecting team may consist of some or all of the therapy team as seems appropriate relative to the
size of the team and wishes of the family.
4. The family should be offered a range of formats including:
Reflecting team joining family and therapist in room.
Family and therapist observing reflecting team through the one way screen.
5. In offering their reflections to the family, team members should ensure they:
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are respectful of family, therapist and team members,
hold a tentative and curious stance,
stay connected to the ideas of the previous contributor,
stay connected with the language used by the family,
use age appropriate language,
do not overwhelm the family with too many ideas,
keep the duration of the reflecting team to no more than 10 minutes.
6. The therapist should take responsibility for monitoring the effect of the reflecting team on the family.
7. The family should always be given the opportunity to offer their comments on the therapy team’s
reflections and ideas.
8. Feedback should be gained from the family about how comfortable and useful they found the process
of the reflecting team, and the ideas the reflecting team shared.
Reflecting Team Example
A reflecting team is used at the end of a session with a father, stepmother, and their two teenage children.
Much of the session has been focused on the difficulties the parents are experiencing in setting consistent
boundaries for the children, especially as they have different parenting styles. They have touched on the
transition to becoming a stepfamily.
RT1: I suppose what struck me in listening to the discussion today was how much Jean and John seem to
have been thinking about pulling together as parents to help give Jack and Jodie clear boundaries of what
they can and can’t do in this family, without wanting too come down too hard on their freedom.
RT2: I was wondering how this pulling together process is affected by the fact that John had to do a lot of
the decision making and parenting on his own for a number of years. Does it feel like a welcome relief to
share things with Jean, or does the extra negotiating make it harder?
RT3: I suppose that would depend on what are the family’s ideas about sharing out roles. I mean I was
wondering whether they see the role of a stepparent as being any different from that of a parent in their
family.
RT1: Yes sometimes the roles can be quite different, each one having its pros and cons. Sometimes a
stepparent can bring a fresh perspective on things, take a step back and look at things in a different way, like
Jean felt she often did. A parent might enjoy a special relationship of understanding because they have been
closer to the child for longer. It may be that these differences could be used to complement each other.
RT3: I was thinking these things might be influenced a lot by gender, because Jean was saying she and
Jodie have developed a closer relationship, partly because they were both women, and there were different
expectations of the things Jean might be able to do as a step-mum.
RT2: It feels like these things take time to negotiate though, and I wonder if this period of negotiation is
what the family are still struggling with, because it might take longer when the children are teenagers, and
have plenty of ideas themselves about how things should be.
RT1: I wondered what ideas the family had of how to take this negotiation further, if it is something they
feel might be worthwhile pursuing. Is it something they would like to discuss here, with us, or do they feel
the negotiation will just evolve naturally?
Th: Perhaps we can leave it there then, and I will take your ideas up with the family.
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4.5 Child Centred Interventions
It will be important for therapists to bear in mind the needs of children within therapy session. Interventions
will need to be tailored to fit their development level, both cognitively and emotionally. Particularly:
The process and implicit rules of therapy may be particularly confusing and anxiety provoking for
children. Engagement should therefore focus on aspects of the world which the child is familiar or is
likely to enjoy. Therapists should use a friendly manner, and try not to raise issues which are likely to
provoke anxiety. It may also be necessary for therapists to clearly and explicitly explain parts of the
therapeutic process which children may find confusing.
Questions will need to be adapted so that children can understand the meaning of questions and the
form of answers that are required. This may require therapist’s to give concrete examples or use names
of individuals to whom they are referring. This is particularly relevant for circular questions which
require respondents to take another’s perspective. Section 4.2
Children are likely to use multiple channels for communication. It is important for therapists not to rely
solely on verbal channels in communicating with children. Drawings, play, and puppetry may all be
helpful in enabling children to communicate their ideas, and therapists should be comfortable in using
these methods with children.
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5. Therapeutic Setting
5.1 Convening Sessions
In setting up the initial therapy session, therapists should begin by discussing the referral information within
the therapy team. In deciding whom to invite to the first session attention should be paid to the following
factors:
Who is living in the household?
Who else is mentioned as important members of the family system?
Recent family life events, that may affect attendance e.g. childbirth / separation.
Is further information required from referrers before therapy can commence?
What professional systems are involved with the family? In relation to:
i. The presenting issues.
ii. Other issues, such as child protection.
Would it be helpful to initiate a professional / network meeting prior to the therapy commencing?
Therapists should first write to the family, using the letter template provided. Appendix I.
A follow up phone call should then be made one week before the initial session to discuss the therapy. As it
is likely that the therapist will only speak to one member of the family during this phonecall, therapists
should ask whoever they speak to, to convey the message to the rest of the family. The topics to be covered
in the phone call are:
Team working
Attendance issues, who will be coming, how to get there, and
ambivalence about attending.
Therapist’s interest in hearing everyone’s ideas
Video recording
Confidentiality
5.2 Team
The team within which you are working should comply with the following guidelines:
Include at least two qualified family therapists (eligible for UKCP registration)
One of the qualified therapists should meet with the family whilst the other forms part of the observing
team.
Team members should have read and incorporated the guiding principles into their thinking. Section 2
Teams should include therapist and family activities in their observations.
Teams should have at least one method for observing the therapist, e.g. one way mirror, in room
observation
Teams should have at least one method of communication between team and therapist, e.g. telephone,
earbug, interruptions.
5.3 Video
There should be capacity to video therapy sessions and permission to video therapeutic work should be
sought from the family in a manner which clearly discusses the video permission they are granting.
Section 6.1 - Permission should be confirmed by using the form provided. Appendix II.
5.4 Pre-therapy preparation
In preparing for the first session the therapist and the team should meet for at least 15 minutes before the
session begins and address the following issues:
Construct a genogram from referral information Genogram example
Summarise the main themes from the referral
Consider the recent life events of the family
Consider difficulties which may arise around engagement and how to address these
Consider broader system issues, and define who is in the network
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Brainstorm themes/hypotheses/formulations which may be relevant to the family
Genograms
Genograms are a means to visually conceptualise the family and wider system, in terms of its members and
relationships. They should include the following information:
All members of the family system, including adopted/fostered members
Delineation of the household
All members of the wider system
Dates of birth
Deaths, with dates
Partnerships and marriages, with dates
Separations and divorces, with dates
Pregnancies, miscarriages, and terminations, with dates
Occupations / Schooling
Any information that is missing from the referral information should be noted and enquired about during the
initial session of therapy.
54
Leonard
dob: ?
m: 1977
d: 1988
44
Carmel
dob: 3.6.54
Tobias
dob: 12.4.27
died : 1967
heart attack
18 16 14 14
Tobias
dob: 10.5.80
Jacob Rachelle Monica
dob: 19.1.82
dob: 12.2.84
bank worker
St James Grammer School
5.5 Pre & Post Session Preparation
m : 1952
Marcia Paul
66
dob: 20.5.32
43 38
28
Leon Brian
dob: 30.7.55 Jean
dob: 13.8.60 dob: ?
Painter
26
Joan
dob: ?
nurse nurse
71
due : Feb 1999
31
Charles
dob: ?
The therapist and therapy team should allow 15 minutes before and after each session to prepare for their
meeting with the family and review the progress of therapy. Issues to be addressed in these discussions
should include:
Pre-Session
Summary of the main themes from previous session
Information which requires clarification from previous session
Between session contact the therapist has had with the family/wider system
The current formulation/themes/hypothesis of the issues with which the family are bringing
Ways forward for the current session which are being considered
Any team – therapist issues which need to be addressed
Any family – family/team issues which need to be addressed
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Post-session
Review of main interventions and family’s response
Ideas for future sessions, themes/issues to follow up,
E.g. narrative prompts, unexplored areas, facts to check
Feedback to therapist of team observations
Therapist’s reflections on issues evoked for them by the session
Review of important information shared, e.g. life events, elements of genogram
5.6 Correspondence
Letters should be used throughout therapy to maintain contact with the family system and the wider
network, as illustrated in this manual. Appendices I, III, IV, V. Throughout this contact, the team’s writing
of the letters should always consider the guiding principles outlined in Section 2. Particularly important are
issues of connecting with the whole system and not locating pathology within individuals. Particular
attention to the language used will be important so that correspondence can be both easily understood, and
reflect the contributions of the family to therapy.
5.7 Case notes
All written records should be non-pejorative, legible, dated, signed, with no abbreviations. Alterations and
Corrections should be clearly marked and signed.
Case notes should include:
Family information sheet
Genogram
Referral information/letter
All other written communications to and from the centre
Record of attendance
Sessions notes
Notes on telephone contacts to and from the centre
5.8 Session notes
The therapy team should make session notes for each meeting between the therapist and family/wider
system. In this way case notes form an observational record of the process of therapy.
Session notes should include :
Date and number of session
Who attended therapy
Therapist/Team member names
Main themes of the session – including key language used by family
Team observations – clearly labelled as impressions
Record of interventions
Key points/ideas/decisions to follow up in later sessions
Team members should record session notes on the record form provided. Appendix VI
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7. Middle Sessions
Goals during middle sessions
1. Develop and Monitor Engagement
2. Gather Information and Focus Discussion
3. Identify & Explore Beliefs
4. Work towards change at the level of beliefs and behaviours
5. Return to Objectives and Goals of Therapy
7.1 Develop engagement
The therapist should pay particular attention to developing a co-constructed therapeutic relationship. In
addition to attending to the three aspects of engagement from the initial meeting (supportive
environment/hearing from everyone/neutrality), attention should be paid to:
Creating and offering choices about the process of therapy
Resolving issues in the family-therapist-team system as they arise. This will require therapists to allow
sufficient time for team discussions pre and post sessions (Section 5.5), and time within sessions to
discuss the process of therapy with families and any concerns or questions they have in relation to this.
7.2 Gather Information & Focus Discussion
Information is still gathered by the therapist, but more of an emphasis should be paid to focusing this
discussion, so that issues and areas for discussion from the initial broad discussions may be looked at in
greater detail or from different perspectives. The therapist plays a role in developing this discussion to
develop themes and keep the discussion focused. Information may often focus on the following topics:
• The presenting difficulties or issues: The therapist will still be gathering information about the
difficulties and issues presented. They will look more closely at the consequences/effects of behaviours.
They should be tracking behavioural patterns, and giving feedback to the family about the behavioural or
emotional interactions and sequences which are discussed or observed. Therapists’ should be collecting this
information in a manner that enables circular descriptions of behaviour to develop.
• The family and wider system: The therapist will still gather information about the family and wider
system as is necessary to understand the information and stories being presented by the family. The
gathering of information about the family should have reduced considerably from the initial sessions. As the
therapist becomes more familiar with who is in the family and their roles, the focus of information should
turn more to relationships.
• Solutions & Successes: The focus on the successes and solutions available to the family should be
steadily increasing throughout therapy.
7.3 Identify & Explore Beliefs
The therapist should identify and explore the family’s thoughts, beliefs, myths or attitudes, which may be
contributing to their dilemmas and difficulties.
The therapist should be beginning to develop a picture of the ideas and beliefs that inform and influence
behaviour, as they are gathering a circular description of the difficulties with which the family are
struggling. Circular questions which build up circular descriptions of behaviour can also be used to explore
the beliefs and assumptions which lie behind those behaviours.
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Example:
Father and stepmother in the family are talking about their parents’ beliefs about childcare, in relation to
being offered numerous solutions from grandparents and friends about how to manage the teenage years.
The therapist is trying to explore ideas about childcare, where these have developed from, and how they
might develop in the future.
Fa: Well my mother would have a lot to say about that. I mean if we were ever like that there was a firm
hand. We would have never have got away with it.
Th: And where do you think your ideas and values about how to manage the children come from, your own
parents?
Fa: Well, not really so much from my parents, I mean I would disagree with a lot of their ideas about how to
do things. I think really I have got more of my guides from the church, that’s what has really shaped me.
Th: And when was it you started to take on the ideas of the church.
Fa: Well I suppose in my late teens, early twenties really, but I have always been interested. Jane
(stepmother) has been going since a child and I would say your family were more strongly Christian than
mine were, wouldn’t you?
Mo: Yes, I have always gone to church.
Th: What are the values from the church that have influenced you as parents?
Mo: Well really a sense of sharing, we feel it’s important for us both to take some interest in the children,
and show them we care, not just one or other of us. But, I don’t know whether we always manage it.
Th: (to the teenage children) When you two are parents where do you think your values will come from?
Son: Well neither of them, well… I suppose I am a bit like dad, maybe I’d be a bit like him.
Th: (To son) And if you were a parent, in their situation as parents now, what might you advise them to do?
The exploration of family beliefs should be used by the therapist to look at a range of family activities, and
not just the presenting difficulties.
Therapists should explore the family’s beliefs in relation to:
The presenting difficulties.
E.g. What ideas has your wife come up with to explain the behaviour John is
showing?
How do you understand the idea that James is less concerned about the
behaviour than Jill?
Relationships within the family and with the wider system.
E.g. Who feels it is most important to keep liasing with the school over this issue?
What would your church say about how families cope with loss and bereavement?
Solutions that have been tried or hypothesised.
E.g. What gave you the confidence to keep going with this new idea?
What gave you the idea to try and tackle things in this manner?
Successes in all areas of family life and relationships to the wider system.
E.g. Would that be judged as a success in your family?
If John’s grandparents were here would they see that as a success, or would
they have different ideas about success?
Therapy process, beliefs about therapy
E.g. What led to your decision not to bring the children to today’s meeting?
In what ways do you think Jill was disappointed with the therapy she went to last year?
Family behaviour during therapy.
E.g. Jill is looking distressed, what do you think was so upsetting for her in talking
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about the difficulties you are experiencing?
How do you understand John’s anger with the way that things have gone in
today’s meeting?
7.4 Work towards change at the level of beliefs and behaviours
Challenge existing patterns and assumptions:
To move with the family to a position where they are able to query their own beliefs, perceptions and
feelings. The therapist should actively query the family’s existing beliefs, assumptions or behaviours. The
use of circular questioning, alternative perspective and possible futures questioning may be particularly
helpful in achieving this.
Example:
A 12-year-old child (John) is discussing how he feels to blame when things in the family go wrong, or there
are arguments between he and his mother. The therapist begins by clarifying what are the child’s
assumptions, then begins to challenge some of the linear aspects of them.
John: Well I know it must be me, cause I am the one who always gets shouted at.
Th: So do you sometimes feel you are to blame for things that happen at home?
John: Well mainly.
Th: Who would be able to convince you otherwise?
John: Well sometimes Nan says things are not my fault, and that me and mum should listen more to each
other, but, I figure it must be me or mum who is at fault.
Th: Does it have to be either your mum to blame or you to blame?
John: Well I don’t know, we are all right together sometimes.
Th: How would your Nan explain the times when you and your mum do get on well together?
John: Well she says we are alright when we stop and listen, sometimes we can just bite off each other’s
heads you see, over nothing, when no-one has really done anything wrong.
Provide distance between the family and the problem:
Providing distance to try and free the family from the pressure of the difficulties, so that they are more able
to consider and reflect upon them. Alternative perspective circular questions and those aimed at looking at
possible futures can often be helpful in achieving this.
Example:
The therapist is talking alone to a mother who has been attending therapy with her children. Since the
separation from her partner she has been finding coping with the demands of the childcare increasingly
arduous, and at times has felt very low about her ability to carry on and cope. The therapist is trying to work
towards creating some distance between the mother and the situation in which she finds herself, to allow a
space for reflection on the position she is in.
Mary: Sometimes I feel so inadequate as a mother, I find myself constantly doubting my own judgement.
Th: If we met with a group of single parents, do you think that would be a concern for most of them?
Would they say making parental decisions alone is very demanding because they may not have immediate
confirmation from another adult?
Mary: Well maybe, but it is so hard because though there is not another adult there, the children are quick
enough to say, other mums don’t do that, or so and so’s mum would let them do this or that.
Th: When your children grow up, do you think they will more fully appreciate the job you do, and your
determination to do your best by them?
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Mary: Well I hope so, I think sometimes they know now how hard things are for me on my own, how much
more running around I have to do, and sometimes how exhausted I am.
Th: When they become parents of their own children, do you think they will see how hard you have been
trying to be both mum and dad at times?
Externalize
One specific way of providing distance between the family and the difficulties, which is particularly useful
if the difficulties are seen to reside within one family member is to externalise the problem. That is to give
the problem an external, objective reality outside of the person. This can be useful in mobilising the family’s
resources to unite in working towards solutions and new ways of thinking which challenge the difficulties.
Example:
The therapist is talking to a 10-year-old boy (Max) during the course of a family meeting. Max has been
describing how bad tempered he can be, especially at school. Family members have been agreeing that Max
is bad tempered. The therapist is working to externalise the temper from Max, in order that he and his
family find ways they can have an influence on the tempers.
Th: Can we give this bad temper a name?
Max: Well, it’s a sort of me at my angriest, a mad max I suppose.
Th: When mad max is around, what effect does he have on your friendships at school?
Max: Well, that when it can be at its worst, mad max can get me to be very argumentative, my friends stay
well away from me.
Th: So when mad max is around they stay away. What happens when mad max isn’t there?
Max: Well I tend to play football with my mates.
Reframe:
Reframe some of the constraining ideas presented by the family. Relabelling in a positive way, ideas and
descriptions given by family members, in a manner which is consistent with their realities. Circular
questions are often most helpful in opening up reframes with the family.
Example
A father is defining himself and his parenting behaviour as the ‘problem’ in relation to his children’s
teenage struggles. The therapist works towards redefining the descriptions of behaviour as less problematic
and offering some positives for the family.
Cl: I think I’m basically just too inconsistent, it depends what mood I am in, or how busy I am, as to what
answer the kids will get from me.
Th: I am just wondering, this inconsistency, who is it a problem for?
Cl: Well them, I think. They don’t know where they stand half the time.
Th: Does it leave people not knowing where they stand or does it leave people having to make up their own
minds?
Cl: Well both, I’ve never really thought about it like that, but I feel like I don’t always think before I react.
Th: Tell me Jane, what are some of the helpful things about your dad just reacting sometimes?
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Open up new stories/explanations:
Either by facilitating the family’s evolution of new ideas and narratives, or by the introduction of these ideas
by the therapist. All family members will have stories about their lives, the lives of other family members,
and the life of the family. They will prioritise certain information from the world around them to build these
stories and neglect other aspects. Exploration of neglected information may open up the development of
stories which are more helpful to the family in coping with their concerns. Information which is neglected
often concerns:
Successes
Solutions
Exceptions
Alternative views from the network
Other strengths
The therapist should pay particular attention to enquiring about this information as therapy progresses, using
circular questions so that the information is provided in a non-threatening manner. Often circular questions,
which are aimed at offering alternative perspectives, can be helpful to this aim. As information is likely to
remain neglected by the family even if introduced into the therapeutic conversation, it can often be helpful
to emphasise neglected information by therapist statements and reflecting team messages.
Example:
Mother: Cindy has always wanted to be a nurse. She entered nurse training but as usual she made a mess of
it. She always does things the hard way. She continued to dream of going away to college, and get on in
some way even after she had failed her exams. She is now doing volunteer auxiliary nursing.
Th: She has continued to work as an auxiliary nurse, she really sounds determined. It seems impressive that
she has found another way to fulfil her ambition, and not let herself get discouraged. Where does she get
that determination from?
Elicit Solutions:
It will be helpful to gather information from the family about solutions for the difficulties that they have
tried or would consider useful. Ideas generated by them are usually most helpful and linear questions are
often used to develop an overview of solutions that the family have tried or thought of. If the family are
finding it difficult to generate successes circular future orientated questions – such as the miracle question -
can be helpful. However at times it may be useful for the therapist or therapy team to offer ideas to begin a
process whereby the family can generate solutions. If this is necessary ideas should be tentative and flexible
enough to allow the family to disregard them or build upon them.
Example:
The therapist is talking to a mother and her three children. They are having difficulties getting along
together, which is intensified by the cramped living accommodation, and their feelings that they don’t have
space for themselves.
Th: So it seems important for you to be able to keep things private, to have space that is your very own.
What ideas have you come up with to achieve this?
Mo: Well we tried letting the children lock their rooms, so that they wouldn’t be in and out of each other’s
rooms, arguing about stuff. But it’s just seemed to cause more arguments, they would just stand outside
each other’s doors screaming to be let in.
Th: So what else did you try then?
Mo: Well we have tried just about everything, you name it we have tried it.
Th: Jane, what does your mum mean? Tell me a bit more about all the things your family have tried.
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Jane: Well when the keys got taken off us, I said Jack and Jodie had to knock on my door, but they never
did, especially him. So mum said we would have to play down stairs all the time, which didn’t last long,
because when I had a friend round I wanted to go upstairs.
Th: So Jack, your sister says you have all being trying hard with ideas about this, can you tell me any other
things that have been tried?
Jack: Nothing else.
Th: Well can you think of other things you think might help which you haven’t tried yet?
Jack: No, nothing seems to work.
Th: Imagine in a month’s time Jane and Jodie had stopped coming into your room, what would have had to
happened to make that possible?
Jack: Well mum might have really told them off when they did it, and said no TV and stuff like that.
Th: Jodie do you think that would stop Jack coming into your room if your mum said that to him?
Jodie: No, he would do it anyway.
Th: What do you think might help Jack to stop coming in?
Jodie: No computer.
Amplify change:
In order to maximise the change or potential change that is occurring throughout the course of therapy it
will be important for the therapist to focus on statements the family present about progress. Initially these
aspects may be minimal, or presented in a manner by the family which denies the magnitude of the effort or
progress they have made. The therapist should focus on descriptions of actions where the family could be
seen to have initiated or implemented change, in a manner which is positive but sensitive to the family’s
level of confidence that change has occurred.
Example:
A 10-year old boy (Jake) is talking about a time when he and he had been pleased about his behaviour,
against a context of difficulties in relationships and communication with his father, as well as difficulties at
school. The therapist explores the event in more detail to emphasise the success and implications of this for
their relationship.
Jake: Well last Thursday we went to the park, and I went on a school trip, and we got to go on a fair ride,
and the teacher said I had been really good.
Th: That sounds like a really nice time, does your mum know about this?
Jake: Yeah, I told her what the teacher had said.
Th: How did your mum react to the good news?
Jake: She was pleased I think.
Th: How did you know? How could you tell your mum was pleased?
Jake: She looked quite happy, and she said we could go to McDonalds on the way home.
Th: (to mother) So you were able to show Jake how pleased you were, how did you feel he responded to
that?
Fa: I was quite surprised actually, we went to McDonalds and he didn’t play up at all, and he told me about
the day, which is a bit of a first for him.
Th: So you noticed you were able to talk more together, what made that possible?
Fa: Well I don’t know, really.
Th: Did you notice you were more relaxed at all?
Fa: Well I suppose that did help, we had a bit of time together because we were out just the two of us, and I
wasn’t wound up so much, cause I was really pleased that he had behaved himself all day?
Th: What would make it possible for you to both find other times in the week when you could have a bit
more time just the two of you, to feel more relaxed and talk.
Enhance mastery:
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To encourage the family to gain a sense of mastery or control over their situation, their thoughts, feelings
and behaviours. This should enable the family members to take responsibility for their own roles and
actions, and for the process of change. In addition should enable family members to gain an awareness of
the actions and motivations of other people in their family in achieving change.
Example:
A mother and her two children aged 5 and 7 years are attending a late middle session of therapy. The
parents separated 3 years ago, and the mother has been finding managing the children’s behaviour difficult
since this time. The therapist and family have been working together through the therapy to identify the
things that the mother is doing well in relation to managing the children’s behaviour and managing her own
low feelings. The therapist is commenting on this process and highlighting the mother’s own stories of
competence which are often lost.
Mo: Well I feel like things have been going quite well with the kids, they have been behaving really well
most times, but I don’t know sometimes I still feel low, I wonder whether I am doing ok. What do you
think?
Th: We would predict many of the things you have been telling me about today, about things being up and
down at this stage. I hesitate to advise a family who have come up with such good ideas and solutions on
their own. Especially when most of them seem to be having the desired effect. What have you been thinking
of trying most recently?
Mo: Well I’m not sure sometimes I feel it’s right to take a sympathetic approach to the kids, then other
times I come down on them hard, you know, if they are playing up.
Th: If Josie (mother’s friend) were looking in on how you were managing them now, would she say you are
combining these two approaches, or are you sticking with one or the other?
Mo: Well she’d see a mix of the both I think, I mean I try and judge each situation as it comes.
Th: So do you feel you are becoming more confident in trusting your judgement about what is right for the
kids and when?
Mo: Well a bit yes, I mean they don’t pull the wool over my eyes, I know when they are just playing up or
when they are really upset.
Th: So when did you decide to be a bit more flexible about how you dealt with the situations at home?
Introduce therapist/team ideas:
May include the therapist sharing their ideas and hypothesis about the family, individual, or difficulties, for
a variety of reasons.
Including:
Normalise difficulties
Move the family to new ideas
Connect family’s ideas
Suggest ways to organise the discussion, e.g. Enactments.
Example:
A mother, her social worker and the therapist are having a session. The mother begins to discuss her
experiences of violence from her ex-partner when she was first married, in her early twenties. As the mother
is taking a rather critical stance towards her own actions at that time, the therapist normalises her reactions
to the violence, to try to begin to open up less critical stories and reframe the mother’s actions at the time as
understandable rather then ‘weak’.
Mo: I suppose I should have been stronger, and not let him trample all over me. My mum used to say just
get out, leave him, and I did for a while, I did try, but then I weakened and let him back even though I
thought why I am I doing this? What about the kids? I really should have tried to be stronger.
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Th: Was your mum the only person with whom you shared this?
Mo: Well I tried to talk to my friend but I felt a bit bad, because all the same stuff had happened to her, and
I just told her to leave and lost patience with her, and then I ended up being just as weak as she was.
Th: From talking to other women who have lived with violence like you have, I often hear a similar story
that they feel they should leave, but it is easier said than done when you are living with that fear on a day to
day basis.
Mo: That was it really, the fear, it kept me weak, and I loved him.
Th: Women tell me they hold onto a hope that if only they did a bit better, were a bit stronger, their partner
will change, so they keep trying over and over again. Did that happen for you?
Mo: Yes, I took him back more than once you see, lots, but then I thought no more, not with the kids seeing
things and all that.
Th: What gave you the strength to put the kids first, and keep sticking to it?
7.5 Return to Objectives and Goals of Therapy
The therapist should return to the issues of goals for therapy as therapy progresses:
i. If goals seemed unclear during the initial stages of therapy, it may take some time and thought with
the family for them to consider the areas they want to change in therapy, or to find priorities for
change.
ii. If goals are achieved, so that goals can be renegotiated, perhaps for change at a wider system level,
or a decision to move towards the end of therapy is made
iii. If goals change due to changing circumstances for the family.
Example:
Things are beginning to improve for a family whose initial concerns were the suicide attempt made by their
daughter. She is no longer suicidal and seems to be getting happier at home and at school. The therapist
discusses with the family whether they are happy with this progress, and whether they are left with other
issues they would like to bring to therapy.
Fa: I mean I think we are all lot more relaxed about Janice now, she was in her room for hours at the
weekend, and I realised at the end of the day that I hadn’t gone and checked on her once, and I figured that
was because I was beginning to trust her again, I mean I didn’t have to watch her every 5 minutes, or worry
what she was up to.
Th: So it seems like all of you are feeling that your concerns that Janice will harm herself are less now, and
Janice you said you felt a bit happier at school. Now these changes are taking place, has it left you with
different ideas about what it could be helpful for us to discuss here?
Janice: Nothing much else to say.
Th: John do you think there are things which Janice might appreciate us talking about here?
John: Well I know she doesn’t like talking about it, and I think that’s half the trouble, but I think maybe we
need to think about how to help Janice cope with all the stuff that goes on at school, all the bullying.
Th: Janice, is that one of the most difficult things for you to talk about?
Janice: Yes.
Th: Would it be helpful to think with you and your family how we could make talking about it easier?
Janice: I’m not sure, there is nothing they can do anyway.
Fa: Me and your mum think if you could talk a bit though, you would like have a shoulder to cry on and not
feel alone.
Th: Do you feel you mum and dad might be able to help support you Janice?
Janice: Yes I suppose so, I did talk to mum once and I felt better.
Th: Would that be something we could try to develop here.
Janice: Well I will give it a go.
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8. End Sessions
Goals during ending sessions
1. Gather Information and Focus Discussion
2. Continue to work towards change at the level of behaviours and beliefs
3. Develop family understanding about behaviours and beliefs
4. Secure Collaborative Decision re: Ending
5. Review the process of therapy
8.1 Gather Information & Focus Discussion
Information gathering and focusing the information brought by the family to sessions is still important
towards the end of therapy, though the focus of the information is likely to be considerably different.
• The Presenting difficulties or issues:
There will still be a lot of information shared about the difficulties with which the family are struggling,
though the focus will be on changes that have arisen concerning these issues over the course of therapy.
• Solutions and Successes to date:
There should be a considerable amount of discussion about the solutions that the family are now
implementing in relation to the difficulties, as well as the successes they feel they have achieved so far, and
those they are looking forward to in the future. If the family are slipping into focusing on the difficulties, it
will be important to enquire further about the successes about which the therapist has heard over the course
of therapy, which the family are currently neglecting.
• The System / Wider system:
There should be a considerable decrease in the amount of information shared about the system and wider
system. Of the information that is shared it is likely to be in relation to how the difficulties are
showing/decreasing in other contexts. Also supports in the wider network which may be drawn upon once
therapy has concluded are often explored.
8.2 Continue to work towards change at the level of behaviours and beliefs
As in middle sessions the therapist and family are continuing to work towards change at the levels of belief
and behaviour. The methods they use can incorporate any of those highlighted in the middle session. See
section 7.4. However it is more common in end sessions for the focus to be on the following methods:
Amplifying change: In order to maximise the change or potential change that is occurring throughout
the course of therapy it will be important for the therapist to focus on statements the family present
about progress. Initially these aspects may be minimal, or presented in a manner by the family which
denies the magnitude of the effort or progress they have made. The therapist should focus on
descriptions of actions where the family could be seen to have initiated or implemented change, in a
manner, which is positive, but sensitive to the family’s level of confidence that change has occurred.
Enhancing mastery: To encourage the family to gain a sense of mastery or control over their situation,
their thoughts, feelings and behaviours. This is to enable the family members to take responsibility for
their own roles and actions, and for the process of change. In addition should enable family members to
gain an awareness of the actions and motivations of other people in their family in achieving change.
Challenging existing patterns and assumptions: To move with the family to a position where they are
able to query their own beliefs, perceptions and feelings. The therapist should actively query the
family’s existing beliefs, assumptions or behaviours. The use of circular questioning, alternative
perspective, and possible futures questioning may be particularly helpful in achieving this.
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Reframing: Reframe some of the constraining ideas presented by the family. Relabelling in a positive
way, ideas and descriptions given by family members, in a manner which is consistent with their
realities. Circular questions are often most helpful in opening up reframes with the family.
Developing new stories and explanations: Either by facilitating the family’s generation of new ideas and
narratives, or the introduction of these ideas by the therapist. All family members will have stories about
their lives, the lives of other family members, and the life of the family. They will prioritise certain
information from the world around them to build these stories and neglect other aspects. Exploration of
neglected information may open up the development of stories to become stories that are more helpful
to the family in coping with their concerns. Information which is often neglected often concerns:
Successes & Solutions
Strengths
Exceptions
Alternative views from the network
8.3 Develop family understanding about behaviours and beliefs
As therapy ends it will be important for the therapist to work with the family to develop and encourage their
understanding of the process of the development of difficulties. This may be helpful in equipping the family
with the ability to recognise the development of such processes in the future. Particular attention should be
paid to:
Underlying family interactional patterns.
Motivations for assumptions, behaviours and feelings.
Understanding of a family member’s reactions to other’s behaviours.
8.4 Collaborative ending decision
The timing of ending is not always obvious and in aiming to make the ending process a collaborative
process the therapist and therapy team should be alert to a number of signals in sessions which may indicate
that therapy may soon draw to a close. These include:
Positive feedback from the family: the family situation or the issues they presented are reported as
improved or improving. The family report having made changes in other areas of their lives.
Negative feedback from the therapy: The family report dissatisfaction about the therapy, or the progress
they are making. This is often done through expressing the views of a family member absent from
therapy.
Therapist notices changes: Missed sessions by the family. Changes in the level of engagement in
therapy. Therapist notices positive changes in the way the family are interacting during sessions, for
example they are beginning to use new narratives, or are beginning to comment in a different way on
their relationships and the issues with which they are struggling. The relationship to therapy may
change, with the family becoming more confident in their own abilities, resources and solutions, and
attributing change to this.
If it seems that ending therapy is indicated it is important for the therapist to hear from everyone their
thoughts and feelings about ending therapy and make this a collaborative decision. To do this the therapist
and therapy team must share their thoughts about ending with each other and the family. The team should
consider the following issues and then gather the family’s views on these.
Whether the family might feel it was appropriate to end therapy, do they feel they have achieved what
they set out to achieve?
How might the family prefer to end therapy, would they like a follow up appointment or would they like
to re-contact the team if necessary?
Might the family feel it would be important to engineer systems of support, before therapy ends?
With whom should the team share information about the therapy and what has been achieved, e.g.
referrer, school.
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9. Indirect Work
There are many areas of systemic work, which although they do not directly involve the presence of the
family, are essential in supporting the ongoing work with the family. Directions for conducting this nondirect
work are therefore outlined below. Therapists are reminded that the guiding principles outlined at the
beginning of this manual will also be applicable to the non-direct work outlined in this section.
9.1 Child Protection
Therapists should abide by the local child protection procedures outlined by their area. Wherever possible
the local procedures should be carried out using the systemic principles described in section 2. It may be
necessary to move from the domain of therapy to the domain of protection but the manner in which this is
achieved should retain a systemic focus, and not preclude the possibility of moving back into the domain of
therapy at a later stage. Therapists should inform the family that they are now not talking with them in their
therapeutic role as they have serious concerns about the safety of a family member. Particular attention
should be paid to bearing the needs of the system in mind whilst still prioritising the needs of the child for
protection, the language and narratives about abuse and protection, and the co-construction of the
relationship. If at all possible, without placing the child at further risk, therapists should discuss the child
protection issues with the family, and keep them informed of any protective procedures that the therapist is
to instigate.
9.2 Clarifying therapy with referrer present
In situations where referrals are vague, complex, or involve a network of professionals, it may be necessary
to clarify the nature and boundaries of the referral over the telephone, or in person. This ideally should be
done with the referrer and family at a pre-therapy meeting, where the multiple views about therapy, its
utility and limits, can be shared between all members of the system. However in referrals where there may
be tensions in the referring relationship, or issues of advocacy may limit the family’s ability to communicate
their ideas and wishes, separate contacts should be used to clarify therapy, before therapy commences.
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9.3 Identifying the network and clarifying relationships
It is important for the therapy team to identify the components of the family’s network from the referral
information given and during the assessment process. This includes professional and extended family
contact, as well as other relationships, friendships and occupational aspects of the family’s life. This should
be done for current relationships as well as important contacts in the family’s history. Important life events
such as illnesses, hospitalisations, and periods of separation can be built into this picture. This information
should be used in relation to the therapeutic goals and in relation to contact with the wider system that the
therapy team and family participates in during therapy.
If the family are participating in any other therapeutic activity during the time they are attending family
therapy, for example individual or couple therapy, the boundaries of the work should be clarified in relation
to the current goals for family therapy.
In addition, in identifying the network and clarifying relationships, the boundaries of confidentiality and the
family’s wishes concerning this should be discussed and clearly stated to all members of the network.
9.4 Assessing risk
At times during therapy it will be necessary to consider the risk which one or more member of the family
poses in relation to their own well being or the well being of a family member. The risk may be in relation
to a number of issues, for example, child protection, domestic violence, or suicide attempts. Therapists
should bring their concerns into the discussion with the family to hear their own views of the risks. It is
important that the therapist’s and family’s concerns are identified, in a manner which opens up
communication and leads to the establishment of contingency plans to monitor or prevent further risks. In
relation to suicidal ideation it may be necessary for the therapist to move outside the domain of therapy and
complete a full psychiatric risk assessment, or refer to someone able to complete this. Again this should be a
process in which the family are actively involved and therapists should inform the family that they are now
not talking with them in their therapeutic role as they have serious concerns about the risks to a family
member.
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10. Proscribed Practices
The proscribed practices described below are things that would not be included in a routine therapy session.
It may be that on one or two occasions it is appropriate to use one of these approaches, however they must
be used within a systemic framework, that is, using the guiding principles outlined at the start of this
manual.
Team members should monitor sessions for proscribed interventions, and record these, together with any
justification, in session notes? Section 5.8
10.1 Advice
As a systemic therapist you would not usually offer direct advice to the family about their interactions or the
difficulties they are experiencing. If the family ask for advice about a particular issue with which they are
struggling or the therapist feels advice may be appropriate in helping the family work towards their goals,
advice may be offered in a non-directive or reflexive manner. Options should be presented as choices about
which the family can make their own decisions.
10.2 Interpretation
Psychodynamic interpretations about the meaning of symptoms or interactions in relation to individual or
trauma would not be usual for systemic therapists. Rather, meanings are explored in relational and
interactional terms between members of the system.
10.3 Un-transparent/Closed Practice
Therapists should not remain closed about their working practices, ways of thinking and understanding the
difficulties with which the family are struggling. They should try to remain transparent by explaining their
practices at the beginning of therapy, and during therapy as appropriate.
10.4 Therapist monologues
In the co-created process of therapy therapists should not find themselves lecturing or using long
monologues in their interactions with the family. The process should be more like a sharing of ideas
between therapist and family, and between family members.
10.5 Consistently siding with one person
In taking a neutral stance therapists should not find themselves consistently siding with one person in the
family. It may be necessary at times, for ethical or therapeutic reasons, to align oneself with a member of
the family, but if therapy is to continue, this should not be a constant state.
10.6 Working in the transference
Therapists should be paying attention to the relational and engagement issues between themselves and the
family with which they are working but they should not use the relational aspects between themselves and
the family as the tool of therapy, that is work within the transference.
10.7 Inattention to use of language
Therapists should not be inattentive to the use of language used by the family. They should pay attention to
the both the words and phrases used, and the meanings attributed to these.
10.8 Reflections
Therapist’s simple reflections of the points or phrases that are used by the family should be kept to a
minimum. Reflections may be used to enhance engagement and to develop the family’s sense of being
listened to and understood, but when used, reflections should be followed by questions, and increased
curiosity about the issues presented.
10.9 Polarised position
Therapists should avoid taking a position which is polarised from that of the family, or a position which is
likely to escalate to a polarised position. Therapists should be thinking about how to take a position which
connects to the ideas of the family, whilst still questioning those ideas, and allowing them to remain curious.
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The therapeutic team can enable the therapist to achieve this by presenting the multiple perspectives from
which the family situation can be understood.
10.11 Sticking in one time frame
Therapists should not stick in one time frame, but move the focus of their questions and discussion between
the past, present and future.
10.12 Agreeing / not challenging ideas
Therapists should not be in a continual state of agreement with the family’s ideas. They should remain
curious and challenging about the nature and content of these ideas, in order to introduce new unexplored
possibilities and ideas.
10.13 Ignoring information that contradicts hypothesis
Therapists should not ignore, or minimise information presented by the family which contradicts their own
ideas and hypotheses, rather they should take this information seriously and use it to modify and expand
their working ideas.
10.14 Dismissing ideas
The ideas presented by the family about the difficulties with which they are struggling, or the process of
therapy itself should not be dismissed by the therapist.
10.15 Inappropriate affect
The therapist’s affect should match that of the family, and would be considered inappropriate if it remained
dissimilar from family for an extended period of time. One example might be if the family were feeling
optimistic about change and the progress they were making, and the therapist remained pessimistic. There
may be times, when a mismatch of affect is used transiently, in order for the therapists to take a position in
relation to the family as a way of questioning or challenging their ideas.
10.16 Ignoring family affect
Therapists should pay attention to the affect that the family is showing in the session, and not ignore strong
expressions of affect during the sessions. This may be particularly relevant when a member of the family
shows distress during the meeting, either by sad or angry behaviour.
10.17 Ignoring difference
Therapists should not ignore issues of difference between themselves and the family or within the family.
These may be differences in views, beliefs, gender, abilities, class or race, and should be raised by the
therapist in a sensitive and open manner for further exploration.
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APPENDIXES
Appendix 1: Sample Appointment Letter
Appointment letters should include:
Referral source and name of referrer
Invitation to the whole family
Reasons why all the household should attend
Date, time and place
Confirmation request
Brief explanation of teamwork
Main therapists name
Dear Mr & Mrs Smith & Jodie and Jonathan,
We have heard from your GP, Dr. Jones, that it might be worthwhile exploring whether family therapy could be
of help to you all. We would therefore like to offer you an appointment to come along and meet us at our
Family Therapy and Research Centre on
Wednesday 13 th July at 4.30pm.
This first session would be to discuss the issues that concern you and to decide whether family therapy might be
useful. We find it helpful to meet all members of the family or household so that we can learn how things are
from everyone's point of view. We hope to see as many of you as possible for this first appointment.
We work as a team in order to generate more ideas which we hope to share with you.
There are about 5 people in the team, but the person who will be talking with you most directly is Dr. Peter
Stratton.
Enclosed is a map giving directions to the clinic, which is situated in the Department of Psychology at Leeds
University.
Please let us know whether or not you can attend, as soon as possible by telephoning our secretary on the above
number. It is important that you give us this information as we have a waiting list for appointments.
Yours sincerely,
Dr Peter Stratton
Family Therapist
On behalf of Leeds Family Therapy Team
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Appendix II: Sample Video Consent Form
Consent Form for the Use of Video Tape
We give consent for the use of these video recordings for the following purposes:
1. To help the team deliver a more effective service to our family. For the purposes of supervision and in order
to plan future therapy sessions. Confidentiality will always be maintained. Viewing will be confined to the
regular members of your family therapy team.
2. For teaching & research, in order to develop our service through training other therapists, and improving
the service for families through research. Such tapes are only shown to audiences of professional clinicians
and researchers who are warned about the importance of confidentiality.
Please delete as appropriate.
Signed: …………………………………………………………………………
………………………………………………………………………………….
Dated: ………………………………………………………………………….
You are entitled to change your mind about the consent given above at any time.
All video material is stored in locked cabinets and every effort will be made to ensure confidentiality. No video
material will be identified using your family’s name.
Signed: …………………………………………………………………………
………………………………………………………………………………….
All Family Members
Dated: ………………………………………………………………………….
Member of Family Therapy Team
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Appendix III: Sample Referrer letter
This letter is to be sent to the referrers when first appointment sent out. It should include:
Referral date
Referral reason
Family name & address
Date of appointment
Proposed future contact
Contact person
Dear Dr. Jones
Re: Smith Family
11 James Avenue, Leeds, LS2
Further to your referral of the Smith family, for help concerning bereavement issues, in March 1998, we have
offered them an appointment at the Leeds Family Therapy and Research Centre on Wednesday 13 th July at
4.30pm.
We will keep you informed of their progress should they go ahead with family therapy.
If in the meantime you have any further issues regarding this family please contact Dr. Peter Stratton.
Yours sincerely
Dr Peter Stratton
Family Therapist
On behalf of Leeds Family Therapy Team
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Appendix IV: Post-assessment letter
A letter should be sent to the referrer once an assessment is completed or when the initial goals of therapy
are clarified with the family. This letter should include:
Number of assessment sessions attended
Who attended
Brief family composition
Referrers concerns
Family’s concerns
Systemic Formulation/Understanding of
Dear Dr. Jones
Re: Smith Family - 11 James Avenue, Leeds, LS2
Difficulties
Agreed Goals for Therapy
Agreed liaison with other systems
I have now seen the Smith family on 2 occasions following your referral for help with bereavement issues following
the death of the eldest child in the family, Julie. Mr & Mrs Smith attended alone for the first meeting, as they were
concerned to give us a picture of the difficulties without upsetting the children. This was followed up with a meeting
with the whole family.
As you know the family consist of Mr & Mrs Smith, and their 2 children Jodie (6 years) & John (9 years), both of
whom are attending Jacob School. The eldest child of the family, Julie, died in a car crash in September 1997.
Mr & Mrs Smith outlined to us their concerns that their children were expressing no grief relating to the death of
their elder sister Julie. They were concerned about how the loss was affecting them in both their achievement
and behaviour at school, and expressed a wish that they were more able to talk about the issue as a family. The
children were quite cautious about discussing this issue initially, and expressed a desire not to upset their parents
further by talking about Julie’s death.
It seemed that although this was a topic all the family felt would be helpful to discuss more openly, no one dared
to begin the conversation, as they were concerned not to bring further distress to members of their family. The
children had carried this silence to school, and would not talk to any of Julie’s old friends about her, yet
consistently showed distress through their behaviour and lack of concentration.
It was therefore decided to try and begin to talk about Julie’s death and the impact this had had on the whole
family in our meetings. The children very much wanted this to be at their pace, and we have been thinking with
them about ways to help the process of talking easier.
We also plan to make links with Jacob school, to discuss how the children might show their distress in different
ways at school.
I will contact you again once therapy has ended to discuss the utility of these interventions for the family.
Yours sincerely,
Dr Peter Stratton
Family Therapist
On behalf of The Leeds Family Therapy Team
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Appendix V: Closing letter to referrer
A letter should be sent to the referrer after therapy has ended and should include:
Reasons and date of original referral.
Number of meetings held
Who attended the meetings
The family’s concerns
Systemic Formulation/Understanding of Difficulties
Themes covered in meetings
Utility of therapy for the family
Evaluation of current state
Future plans
Copies to other agencies involved, with family’s permission
Dear Dr Jones
Re: Smith family - 11 James Avenue, Leeds, LS2.
You will remember you referred the Smith family for family therapy in March 1998, for help with
bereavement issues.
The family attended for 5 appointments. We saw them last in November 1998 and a further appointment
for December was cancelled. All members of the family attended meetings following an initial meeting
with Mr & Mrs Smith alone.
The parents outlined to us their concerns that their 2 children Jodie (6years) & John (9years), were
expressing no grief relating to the death of their elder sister Julie, who died in a car crash in September
1997. Mr & Mrs Smith were concerned about how the loss was affecting them in both their achievement
and behaviour at school, and expressed a wish that they were more able to talk about the issue as a family.
Our 5 meetings were spent looking at the effect Julie’s death had had on both the parents and the children,
and the stories they had developed for understanding what had happened. At the family’s request we also
invited the Headmistress of the children’s school, Mrs Small, to look at ways the children could express
their grief about Julie’s death within the school setting. In addition we thought about ways they might be
supported to develop their concentration, when distracted or upset at school.
The family used all of the meetings to their fullest, and communication concerning the bereavement
improved very rapidly. The children also reported feeling happier at school.
We had planned to continue, but the family phoned and left a message to say they felt things had
improved at home and at school and they would contact us again if the need arose. We left it with them
that we would be very happy to see them again if requested.
Yours sincerely
Dr Peter Stratton
Family Therapist
On behalf of The Leeds Family Therapy Team
c.c. Mrs Small, Headmistress, Jacob School
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Appendix VI : Session Notes Record Form
SYSTEMIC FAMILY THERPY MANUAL
SESSION NOTES
Record Sheet
Date of Session Session Number
Who attended therapy?
Therapist name
Team member names
Main themes of the session Include key language used by family
Main themes continued
Team observations Clearly labelled as impressions
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Interventions
Key points/ideas/decisions to follow up in later sessions
1.
2.
3.
Proscribed Practices included in session
1.
2.
3.
Justification
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Appendix VII – Diagonistic Interview Outline
I. Generally:
MULTIPLE FAMILY GROUP THERAPY
DIAGNOSTIC INTERVIEW OUTLINE
©1993 by Lewis N. Foster
A. Work toward an active interpretation of content, but focus on process, and have fun;
B. Be as unbiased as possible in your observation of the families, don't be judgmental;
C. Establish the therapists' control --- a therapist must be in control because dysfunctional families are not in
control. The families will feel secure that the therapist can handle, and not be shocked by, what happens
in the multiple family group therapy session.
D. Where in the family life-cycle are the families, and at what stage of development are the family members?
II. Methods (see the Evaluation and Session Guide form):
A. Take the time to make the families as comfortable as possible. Treat them as though they are in your
living room.
B. Select out the important family themes. A theme(s) will emerge very early in the session. Help the
families to stick with the theme(s) instead of wandering. It is more gainful for both the families and the
therapist.
C. Once a theme is selected it should be discussed by each family member. Encourage interaction between
the families regarding the theme, taking the theme back to the therapist for clarification if the discussion
becomes punitive in nature.
D. Try to delineate areas of consensus among family members on problem issues. Point out commonalities
between families.
E. Summarize and reframe as needed.
F. Contract with the families for three sessions. It will be easier to get the families to agree to three sessions
than eight or ten, for example. Know that around the third or forth session each family will come to the
group in crisis. This will help you keep the family in treatment for another three sessions. Begin to think
about what the crisis may be about.
G. Establish as definitely as possible the conditions for treatment. Clarify the therapist's expectations (for
example, who is expected to attend) and maintain an orientation to the presenting problem(s).
H. Some education on Enhancing Intimacy, Managing Conflict, Parenting, Dependency, or other issues may
be needed.
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III. Assessment (see Assessing The Family Dance) is an on going process from session to session and is
done in the Multiple Family Therapy Group:
A. Investigate the internal organization of the families (their family dance).
1. What kind of support do they give each other and how do they communicate intimacy?
2. What kind of satisfaction of needs do they supply for each other?
3. What are the patterns of communication?
4. What are the lines of authority and who is the functioning head of the individual families?
5. How do the families share pleasures and problems?
6. What are the sex identities and sex roles in the families?
7. What are the parent-child interactions about?
8. What are the alliances between family members?
9. What is the value system of the families?
10. What are the struggles and goals?
11. Who becomes a leader in the group?
B. The external organization of patterns of interaction of the families (their connection with society).
1. What are the contacts with the outside?
a. social network
b. kin network
c. church
2. What is their position in their sub-cultural system?
a. economic
b. race
c. kinship
d. social
C. Conflicts, Conflict Styles, and Themes.
1. What are the sources of conflict?
2. What are the resources and available coping mechanisms mobilized to deal with conflicts?
Ways of coping can include the following:
a. Intensification of some dyadic relationships.
b. The mobilization of some outside or external support such as peers, neighbors, the paramour, or
other "sympathetic ears."
c. Change of environment for one or more family members.
d. Re-peopling, or an increase or decrease in family participants as occurs with marriage, birth, death,
divorce, extended family moving in, pets, etc.
e. Reorganization of roles.
f. Emotional divorce or distancing, (this includes the "pseudomutual" relationship which is emotional
distancing with accompanying complete denial of that distancing. Pseudomutual couples operate as if
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they are in complete agreement. There exists a pretense of lack of conflict in the midst of much
difficulty with accompanying fear and/or incapacity to come close. Pseudomutuality may break up
via the paramour).
g. Compromise.
h. Scapegoating.
i. Healing, or an escape to health (healing is often seen in conjunction with scapegoating).
3. What are the pathogenic features used to deal with conflicts?
D. Affect, Mood and Family Processes.
1. What are the affects (feelings and emotions conveyed by means of facial expressions) and moods of
the families?
2. How do the families carry out affect and mood?
E. Family Systems and Subsystems.
1. Marital Relationships
a. The positives and negatives of the couples' sexual and emotional life.
b. The perception of each other and of each other's role (this is also known as delineation, or the
perception that a person has of his mate as seen through the behavior that both exchange and how
each fits into the frame of the other's future needs).
c. The stability of the marital relationships.
d. The ways in which each spouse is separate and autonomous from each other, her/his family of
origin, and others in the group.
e. The role of adaptation of each partner.
2. Parenting Relationships
a. How the parents cope with their children's social maturation outside the home and in the MFT
group.
b. Are there clear lines structurally between the parenting and marital relationships?
c. Is there functional parental authority?
d. At what developmental stages are the children?
3. Sibling Relationships
a. The way the siblings organize themselves to educate the parents.
b. The support they give each other in the process of each sibling's maturation or striving for
independence.
4. Extended Family Relationships
a. Have the parents successfully left home?
b. Are grandparents actively involved in the parenting of the children?
c. How involved are other extended family members?
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BASIC FAMILY THERAPY TECHNIQUES
ACCOMMODATION
IN ALPHABETICAL ORDER
The therapist makes personal adjustments in order to achieve a therapeutic alliance.
Accommodating is: adapting to a family's communication style. – (Also see: “joining”)
ADVICE & INFORMATION
These are derived from experience and knowledge of the family in therapy. They are used to calm down anxious
members of families or reassure these individuals and families about certain actions.
AFFECTIVE CONFRONTATION
Affective Confrontation of Rigid Patterns and Roles is used to interrupt rigid patterns.
The goals may be
a/ to raise clients' awareness when they do not know how they are contributing to the problem.
b/ to raise a taboo subject that the client and others have been avoiding, or
c/ to increase motivation to make changes when there is cognitivie awareness but no change in action.
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Examples:
"When did you divorce your husband and marry your son?"
"You are aware that you have abandoned the family to advance your career?"
"What do you think would be more detrimental for your daughter: missing dance practice once a week for a few
months or having her parents divorce? Do you want to ask your child what her preference is?"
ASKING PERMISSION
Narrative therapists use permission questions to emphasize the democratic nature of the therapeutic relationship
and to encourage clients to maintain a clear, strong sense of agency when talking with the therapist.
Asking permission to ask a question goes against the prevailing assumption that therapists can ask any question
they want tot gather information they purportedly need to help the client. Many clients feel compelled to
answer these questions, even if they are not comfortable doings so.
Narrative therapists show their sensitivity by asking permission before asking questions that are generally taboo
or concern difficult objects.
Example:
"Would it be okay if I ask you some questions about your sex life?"
In addition, throughout the interview, the therapist may ask for client input and permission to continue with a
particular topic or line of questioning.
BEGINNER’S MIND
"In the beginner's mind there are many possibilities, in the expert's mind there are few"
Position of curiosity. Viewing experiences as though for the first time.
A beginner's mind is very open, very alert. It is not filled with ideas and notions, truths and dogmas. It is
receptive.
BOUNDARY FORMATION
Part of the therapeutic task is to help the family define, or change the boundaries within the family. The
therapist also helps the family to either strengthen or loosen boundaries, depending upon the family’s situation.
Boundary making is a special case of enactment, in which the therapist defines areas of interaction that he rules
open to certain members but closed to others. When Minuchin prevents the husband from “helping” his wife to
discipline the girls, he is indicating that such specific transaction is for the mother and daughters to negotiate,
and that father has nothing to do at this point; this specific way of making boundaries is also called blocking.
Other instances of boundary making consist of prescriptions of physical movements: a son is asked to leave his
chair (in between his parents) and go to another chair on the opposite side of the room, so that he is not “caught
in the middle”; a grandmother is brought next to the therapist and far from her daughter and granddaughters who
have been requested to talk; the therapist himself stands up and uses his body to interrupt visual contact between
father and son, and so forth.
Boundary making is a restructuring manoeuvre because it changes the rules of the game. Detouring mechanisms
and other conflict avoidance patterns are disrupted by this intervention; underutilized skills are allowed and
even forced to manifest themselves. The mother of the 5 year old is put in the position of accomplishing
something without her husband’s help; husband and wife can and must face each other without their son acting
as a buffer; mother and daughter continue talking because grandma’s intervention, which usually puts a period
to their transactions, is now being blocked; father and son can not distract one another through eye contact.
As powerful as the creation of specific events in the session may be, their impact depends to a large extent on
how the therapist punctuates those events for the family. (Jorge Colapinto – Structural Family Therapy)
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ADDING COGNITIVE CONSTRUCTIONS
1.Advice & Information
are derived from experience and knowledge of the family in therapy. They are used to calm down anxious
members of families or reassure these individuals and families about certain actions.
2. Pragmatic fictions
are formal expressions of opinion to help families and their members change.
3. Paradox
is an apparently sound argument leading to a contradiction. It is used to motivate family members to search or
alternatives. Family members may defy the therapists and become better or they may explore reasons why their
behaviours are as they are and make changes in the ways members interact.
COMMUNICATION TECHNIQUES
1. MATCHING THE CLIENT’S LANGUAGE
Example: Use the exact words the client uses to describe the problem in asking questions about what they have
done before, when it is not so serious a problem, etc.
Also, attend to client’s metaphors and utilize them also to extend observations, learn about their interests or
hobbies to use metaphors that involve them.
2. MATCHING SENSORY MODALITIES
Use words pertaining to “seeing” or “hearing” how things are and use words in the same vein.
3. CHANNELING THE CLIENT’S LANGUAGE
Channel away from jargon into action descriptions used in every day language. This has the effect of
depathologizing or normalizing clients’ situations. Gradually change your terminology to less serious, more
positive words. (Example: Use the words “transitional period” as this give the client the opportunity to take
solace in hearing that a problem is temporary, helps shape their expectations for the future).
4. USE OF VERB FORMS
Create a reality where the problem is in the past and possibilities exist for the present and in the future. “When
you had this problem before, you used to . . you were having difficulty . . how did the old you . . .” - Help
clients make distinctions that are helpful (feeling like or thinking about . . . rather than doing it).
5. GIVE CLOSE EXAMINATION TO THEIR LANGUAGE AND YOURS.
A. Vague statements
B. Unspecified verbs : “He ruined the relationship” (how, what way?). “I am scared” (of what)
C. Specify comparison: “He is lazy” (compared to whom)
D. Empty nouns: respect, love, anger, depression
E. Generalization: all, none, always, never
F. Cannot/will not vs. doesn’t /did not
G. Characterizations lazy, aggressive
H. Challenge claims: “How do you know you feel depressed”
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COMMUNICATION SKILL-BUILDING TECHNIQUES
More often than not, it's a family's communication patterns and styles that lead to conflict and division.
Communication patterns and processes are often major factors in preventing healthy family functioning. Faulty
communication methods and systems are readily observed within one or two family sessions. A variety of
techniques can be implemented to focus directly on communication skill building between a couple or between
family members.
Communication techniques are used to build skills that allow for effective communication between family
members.Listening techniques including restatement of content, reflection of feelings, taking turns expressing
feelings, and nonjudgmental brainstorming are some of the methods utilized in communication skill building.
1. REFLECTING
involves having a member express her feelings and concerns, then having another member repeat back what he
heard that person say.
2. REPEATING
techniques involves having a member state how he feels, while another member repeats back what was said.
Repeating and reflecting techniques allow members to better understand where the other is coming from and
why she feels as she does.
3. FAIR FIGHTING TECHNIQUES
focus on attentive listening and expressing feelings and concerns in a nonthreatening manner.
CONCLUSION
The techniques suggested here are examples from those that family therapists practice. Counsellors will
customize them according to presenting problems. With the focus on healthy family functioning, therapists
cannot allow themselves to be limited to a prescribed operational procedure, a rigid set of techniques or set of
hypotheses. Therefore, creative judgment and personalization of application are encouraged.
CONFIRMATION OF A FAMILY MEMBER:
Using an affective word to reflect an expressed or unexpressed feeling of that family member.
The therapist can join families from different positions of proximity.
In the close position of proximity, he can affiliate with family members, perhaps even entering into coalition
with some members against others.
Probably the most useful tool of affiliation is confirmation.
The therapist validates the reality of the family member(s) he joins. He searches out positives and makes a point
of recognizing and awarding hem.
DEFRAMING
Deframing is a strategy that works hand-in-hand with normalization. Like normalization, deframing is useful in
many areas of therapy, but it can be particularly effective with involuntary clients. Deframing is defined as a
strategy that introduces uncertainty into the client’s present and past view of things which have not been shown
to be useful (O’Hanlon & Beadle, 1997 p. 35). Generally speaking, deframing focuses on the process of
deconstructing past or present embedded, nonfunctional beliefs. It begins that process by introducing
uncertainty into the therapeutic conversation.
The therapist functions from a position of influence. What a therapist says or does not say in the course of a
therapeutic interview influences the client. What is emphasized or ignored also makes a difference. Wording,
phrasing, interrupting, or remaining silent: all influence what the client is feeling and thinking in the therapeutic
relationship.
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In fact, for any given client statement, the therapist has the choice to take that statement in many directions.
These choices usually involve—in some way—reifying the problem (i.e., lending credence to the fact that there
is a problem).
Deframing is another option. It works in the opposite direction of reification, and it effectively challenges the
existence—or at least the power—of the problem (O’Hanlon & Weiner-Davis, 1989, pp. 52–53).
Because postmodernist therapy views the congruent therapist a forming a system with the client, the therapeutic
unity that evolves in that process represents a co-creative effort at finding a solution or dissolution to the
problem. And so, it becomes clear that deframing—introducing uncertainty and doubt into the client’s
cosmos—can be a powerful tool for influencing the client when dealing with a client’s dysfunctional, useless
embedded beliefs.
Examples of Deframing Questions
- How do you know that to be so?
- What makes you say that?
- How is that so?
- Where did you get that idea?
- On what basis have you reached that conclusion?
- What do you think is the origin of that belief?
- What is the foundation on which you rest your case?
- Did you ever have any doubts about those thoughts?
- Are you sure that’s accurate?
- What makes you so sure?
- What are the benefits in believing that?
- What influenced you to think along those lines?
- Why would you want to stick with that belief?
Example of a Deframing Sequence
Therapist: How do you know that having a baby now will make you feel better?
Client: It’ll be part of me. It’ll be something I can call my own.
T: How is it important for you, right now, to have something you can call your own?
C: It’s normal. That’s for sure.
T: And what makes you say that?
C: It’s all around me.
T: What’s all around you?
C: Kids.
T: I’m sorry. I don’t understand. What does that mean?
C: You know. Kids! My mother had 10. Lots of my girlfriends already have one or two.
T: And how old are your friends?
C: Sixteen.
T: How is it that they had children at 16?
C: Well, there’s no sense going to school if you’re failing semester after semester.
T: So, they were failing all along?
C: Yes. They were.
T: I understand you’re still attending school. How are you doing in school?
C: Barely hanging in there.
T: Barely? How’s that?
C: I’m passing, but barely passing.
T: What are some things that passing could mean to you?
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C: I don’t know. I guess a lot of things: bad and good.
T: Could you describe for me some of the good things?
Deframing can be especially useful in the preceding example because it avoids a possible confrontation with a
person who is firmly entrenched in an opposing belief system. It also avoids a certain kind of preachiness that
can easily deteriorate the immediate relationship with the client. Deframing, as a deconstructive tool,
effectively calls into question the validity of a client’s beliefs and motivations. In most cases, employing logic,
for instance, a direct common-sense approach exhorting the teenager to stay in school and not have children,
could easily prove to be ineffectual. Dealing with beliefs or belief systems head-on, in this case with an
adolescent mindset, not always grounded in long-range perspectives, is usually doomed to failure. Deframing,
instead, seems to offer a greater opportunity for success at penetrating a deeply embedded belief by inserting
doubt into the client’s mindset.
Deframing is achieved by calling into doubt the client’s beliefs or belief system. Another strategy related to
deframing deals with the entire area of what a client may have intended but was not subsequently realized, or
was manifested in strange and not easily recognizable ways. Positive connotation, a strategy that is easily
overlooked, calls into play the whole area of client intentions, which can yield valuable information.
DETRIANGULATION
The process by which an individual removes himself or herself from the motional field of two others.
(triangulation is: Detouring conflict between two people by involving a third person, stabilizing the relationship
between the original pair.)
DIAGNOSING
Diagnosing is done early in the therapeutic process. The goal is to describe the systematic interrelationships of
all family members to see what needs to be changed or modified for the family to improve. By diagnosing
interactions, therapists become proactive, instead of reactive.
DIFFERENTIATION OF SELF
Psychological separation of intellect and emotions and independence of self from others; opposite of fusion.
(Fusion is a blurring of psychological boundaries between self and others and a contamination of emotional and
intellectual functioning; opposite of differentiation.)
DISEQUILIBRIUM TECHNIQUES
The following techniques are used to create a different perception of reality.
1. REFRAMING:
The technique of reframing is a process in which a perception is changed by explaining a situation in terms of a
different context. For example, the therapist can reframe a disruptive behaviour as being naughty instead of
incorrigible allowing family members to modify their attitudes toward the individual and even help him or her
makes changes.
Reframing is putting the presenting problem in a perspective that is both different from what the family brings
and more workable. Typically this involves changing the definition of the original complaint, from a problem of
one to a problem of many. In a consultation (Minuchin, 1980) with the family of a 5-year-old girl who is
described by her parents as “uncontrollable,” Salvador Minuchin waits silently for a couple of minutes as the
girl circles noisily around the room and the mother tries to persuade her to behave, and then he asks the mother:
“Is this how you two run your lives together?” If the consultant had asked something like “Is this the way she
behaves usually?” he would be confirming the family’s definition of the problem as “located” in the child; by
making it a matter of two persons, the consultant is beginning to reframe the problem within a structural
perspective.
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ln the quoted example the consultant is feeding into the system his own reading of an ongoing transaction.
Sometimes a structural family therapist uses information provided by the family as the building materials for his
frame. Minutes later in the same session, the mother comments: “But we try to make her do it,” and the father
replies “I make her do it.” Minuchin highlights then this brief interchange by commenting on the differences
that the family is presenting: mother can not make her do it, father can. The initial “reality” described just in
terms of the girl’s “uncontrollability” begins to be replaced by a more complex version inv9lving an ineffective
mother, an undisciplined child, and maybe an authoritarian father.
The consultant is reframing in terms of complementarity, a typical variety of the reframing technique, in which
any given individual’s behavior is presented as contingent on somebody else’s behavior. The daughter’s
uncontrollability is related to her mother’s ineffectiveness which is maintained by father’s taking over— which,
on the other hand, is triggered by mother’s ineffectiveness in controlling the daughter. Another example of
reframing through complementarity is the question “Who makes you feel depressed?” addressed to a man who
claims to be “the” problem in the family because of his depression.
As with all other techniques employed in structural family therapy, reframing is based on an underlying attitude
on the part of the therapist. He needs to be actively looking for structural patterns if he is going to find them and
use them in his own communications with the family. Whether he will read the 5-year-old’s misbehavior as a
function of her own “uncontrollability” or of a complementary pattern, depends on his perspective. Also, his
field of observation is so vast that he can not help but be selective in his perception; whether he picks up that “I
make her do it” or lets it pass by, unnoticed amidst the flow of communication, depends on whether his selective
attention is focused on structure or not. As with joining, as with unbalancing, reframing requires from the
therapist a “set” without which the technique can not be mastered.
The reframing attitude guides the structural family therapist in his search of structural embeddings for
“individual” problems. In one case involving a young drug addict, the therapist took advantage of the sister’s
casual reference to the handling of money to focus on the family’s generosity toward the patient and the
infantile position in which he was being kept. In another case, involving a depressed adolescent who invariably
arrived late at his day treatment program, the therapist’s reframing interventions led to the unveiling of a pattern
of overinvolvement between mother and son: she was actually substituting for his alarm-clock. In an attempt to
help him she instead was preventing him from developing a sense of responsibility.
The intended effect of reframing is to render the situation more workable. Once the problem is redefined in
terms of complementarity -for instance, the participation of every family member in the therapeutic effort
acquires a special meaning for them. When they are described as mutually contributing to each other’s failures,
they are also given the key to the solution. Complementarity is not necessarily pathological; it is a fact of life,
and it can adopt the form of family members helping each other to change. Within such a frame, the therapist
can request from the family members the enactment of alternative transactions.
2. ENACTMENT:
Enactment is the actualization of transactional patterns under the control of the therapist. This technique allows
the therapist to observe how family members mutually regulate their behaviors, and to determine the place of
the problem behavior within the sequence of transactions. Enactment is also the vehicle through which the
therapist introduces disruption in the existent patterns, probing the system’s ability to accommodate to different
rules and ultimately forcing the experimentation of alternative, more functional rules. Change is expected to
occur as a result of dealing with the problems, rather than talking about them.
In the case of the uncontrollable girl, the consultant, after having reframed the problem to include mother’s
ineffectiveness and father’s hinted authoritarianism, sets up an enactment that will challenge that “reality” and
test the family’s possibilities of operating according to a different set of assumptions. He asks the mother
whether she feels comfortable with the situation as it is—the grown ups trying to talk while the two little girls
run in circles screaming and demanding everybody’s attention. When mother replies that she feels tense, the
therapist invites her to organize the situation in a way that will feel more comfortable, and finishes his request
with a “Make it happen” that will be the motto for the following sequence.
The purpose of this enactment is multileveled. At the higher, more ambitious level, the therapist wants to
facilitate an experience of success for the mother, and the experience of a successful mother for the rest of the
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family. But even if mother should fail to “make it happen” the enactment will at least fulfill a lower-level goal:
it will provide the therapist with an understanding of the dysfunctional pattern and of the more accessible routes
to its correction.
In our specific example, the mother begins to voice orders in quick succession, overlapping her own commands
and hence handicapping her own chances of being obeyed. The children seem deaf to what she has to say,
moving around the room and only sporadically doing what they are being asked to do. The consultant takes
special care to highlight those mini-successes, but at the same time he keeps reminding the mother that she
wanted something done and “It is not happening—make it happen.” When father, following the family rule,
attempts to add his authority to mother’s, the consultant blocks his intervention. The goal of the enactment is to
see that mother “makes it happen” by herself; for the same reason, the consultant ignores mother’s innumerable
violations to practically every principle of effective parenting. To correct her, to teach her how to do it would
defeat the purpose of the enactment.
The consultant keeps the enactment going on until the mother eventually succeeds in organizing the girls to play
by themselves in a corner of the room, and then the adults can resume their talk. The experience can later be
used as a lever in challenging the family’s definition of their reality.
If mother had not succeeded, the consultant would have had to follow a different course—typically one that
would take her failure as a starting point for another reframing. Sometimes the structural family therapist
organizes an enactment with the purpose of helping people to fail. A classical example is provided by the
parents of an anorectic patient who undermine each other in their competing efforts to feed her. In this situation
the therapist may want to have the parents take turns in implementing their respective tactics and styles, with the
agenda that they should both fail and then be reunited in their common defeat and anger toward their
daughter—now seen as strong and rebellious rather than weak and hopeless.
Whether it is aimed at success or at failure, enactment is always intended to provide a different experience of
reality. The family members’ explanations for their own and each other’s behaviors, their notions about their
respective positions and functions within the family, their ideas about what their problems are and how they can
contribute to a solution, their mutual attitudes are typically brought in-to question by these transactional microexperiences
orchestrated by the therapist.
Enactments may be dramatic, as in an anorectic’s lunch (Rosman, Minuchin & Liebman, 1977, pp. 166—169),
or they can be almost unnoticeably launched by the therapist with a simple “Talk to your son about your
concerns, I don’t know that he understands your position.” If this request is addressed to a father that tends to
talk to his son through his wife, and if mother is kept out of the transaction by the therapist, the structural effects
on behavior and perception may be powerful, even if the ensuing conversation turns out to be dull. The real
power of enactment does not reside in the emotionality of the situation but rather in the very fact that family
members are being directed to behave differently in relation to each other. By prescribing and monitoring
transactions the therapist assumes control of a crucial area—the rules that regulate who should interact with
whom, about what, when and for how long.
3. BOUNDARY MAKING
Boundary making is a special case of enactment, in which the therapist defines areas of interaction that he rules
open to certain members but closed to others. When Minuchin prevents the husband from “helping” his wife to
discipline the girls, he is indicating that such specific transaction is for the mother and daughters to negotiate,
and that father has nothing to do at this point; this specific way of making boundaries is also called blocking.
Other instances of boundary making consist of prescriptions of physical movements: a son is asked to leave his
chair (in between his parents) and go to another chair on the opposite side of the room, so that he is not “caught
in the middle”; a grandmother is brought next to the therapist and far from her daughter and granddaughters who
have been requested to talk; the therapist himself stands up and uses his body to interrupt visual contact between
father and son, and so forth.
Boundary making is a restructuring manoeuvre because it changes the rules of the game. Detouring mechanisms
and other conflict avoidance patterns are disrupted by this intervention; underutilized skills are allowed and
even forced to manifest themselves. The mother of the 5 year old is put in the position of accomplishing
something without her husband’s help; husband and wife can and must face each other without their son acting
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as a buffer; mother and daughter continue talking because grandma’s intervention, which usually puts a period
to their transactions, is now being blocked; father and son can not distract one another through eye contact.
As powerful as the creation of specific events in the session may be, their impact depends to a large extent on
how the therapist punctuates those events for the family.
4. PUNCTUATION:
Punctuation is “the selective description of a transaction in accordance with a therapist’s goals”. Therefore it is
verbalizing appropriate behaviour when it happens.
Punctuation is a universal characteristic of human interaction. No transactional event can be described in the
same terms by different participants, because their perspectives and emotional involvements are different. A
husband will say that he needs to lock himself in the studio to escape his wife’s nagging; she will say that she
can not help protesting about his aloofness. They are linked by the same pattern, but when describing it they
begin and finish their sentences at different points and with different emphases.
The therapist can put this universal to work for the purposes of therapeutic change. In structural family therapy
punctuation is the selective description of a transaction in accordance with the therapist’s goals. In our example
of enactment, the consultant organized a situation in which the mother was finally successful, but it was the
consultant himself who made the success “final.” Everybody—the mother included—expected at that point that
the relative peace achieved would not last, but the consultant hastened to put a period by declaring the mother
successful and moving to a different subject before the girls could misbehave again. If he had not done so, if he
had kept the situation open, the usual pattern in which the girls demanded mother’s attention and mother became
incompetent would have repeated itself and the entire experience would have been labeled a failure. Because of
the facts of punctuation, the difference between success and failure may be no more than 45 seconds and an alert
therapist.
Later in the same session the consultant asked the parents to talk without allowing interruptions from their
daughter. The specific prescription was that father should make sure that his wife paid attention only to him and
not to the girl. Given this context for the enactment, whenever mother was distracted by the girl the therapist
could blame father for the failure—a different punctuation from what would have resulted if the consultant had
just asked mother to avoid being distracted.
A variety of punctuation is intensity, a technique that consists of emphasizing the importance of a given event in
the session or a given message from the therapist, with the purpose of focusing the family’s attention and energy
on a designated area. Usually the therapist magnifies something that the family ignores or takes for granted, as
another way of challenging the reality of the system. Intensity is achieved sometimes through repetition: one
therapist put the same question about 80 times to a patient who had decided to move out of his parents’ home
and did not do so: “Why didn’t you move?” Other times the therapist creates intensity through emotionally
charged interventions (“It is important that you all listen, because your sister can die”), or confrontation (“What
your father did just now is very disrespectful”). In a general sense, the structural family therapist is always
monitoring the intensity of the therapeutic process, so that the level of stress imposed on the system does not
become either unbearable or too comfortable.
4. UNBALANCING:
This is a procedure wherein the therapist supports an individual or subsystem against the rest of the family.
When this technique is used to support an underdog in the family system, a chance for change within the total
hierarchical relationship is fostered.
Unbalancing is a term that could be used to encompass most of the therapist’s activity since the basic strategy
that permeates structural family therapy is to create disequilibrium. In a more restricted sense, however,
unbalancing is the technique where the weight of the therapist’s authority is used to break a stalemate by
supporting one of the terms in a conflict.
Toward the end of the consultation with the family of the “uncontrollable” girl, Minuchin and the couple discuss
the wife’s idea that her husband is too harsh on the girls:
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Minuchin. Why does she think that you are such a tough person? Because I think she feels that you are very
tough, and she needs to be flexible because you are so rigid. I don’t see you at all as rigid, I see you actually
quite flexible. How is that your wife feels that you are rigid, and not understanding?
Husband: I don’t .know, a lot of times I lose my temper I guess, right? That’s probably why.
Wife: Yeah.
Minuchin: So what? So does she. I have seen you playing with your daughter here and I think you are soft and
flexible, and that you were playing in a rather nice and accepting way. You were not authoritarian, you had
initiative, your play engaged her. . . . That is what I saw. So why is that she sees you only as rigid and
authoritarian, and she needs to defend the little girls from your (punches father’s knee)? I don’t see you that way
at all.
Husband: I don’t know, like I say, the only thing I can think of, really, is because I lose my temper with them.
Wife: Yes, he does have a short fuse.
Minuchin: So what? So do you.
Wife: No, I don’t.
Minuchin: Oh you don’t. Okay, but that doesn’t mean that you are authoritarian, and that doesn’t mean that you
are not understanding. Your play with your daughter here was full with warmth and you entered very nicely, and
as a matter of fact she enjoyed the way in which you entered to play. So, some way or other your wife has a
strange image of you and your ability to understand and be flexible. Can you talk with her, how is that she sees
that she needs to be supportive and defending of your daughter? I think she is protecting the girls from your
short fuse, or something like that. Talk with her about that, because I think she is wrong.
Wife: That’s basically what it is, I’m afraid of you really losing your temper on them, because I know how bad
it is, and they are little, and if you really hit them with a temper you could really hurt them; and I don’t want
that, so that’s why I go the other way, to show them that everybody in the house doesn’t have that short fuse.
Husband. Yes, but I think when you do that, that just makes it a little worse because that makes her think that
she has somebody backing her, you know what I mean?
Minuchin (shakes husband’s hand): This is very clever, and this is absolutely correct, and I think that you should
say it again because your wife does not understand that point.
In this sequence the consultant unbalances the couple through his support of the husband. His focus organizes
him to disregard the wife’s reasons, which may seem unfair at first sight. But it is in the nature of unbalancing to
be unfair. The therapist unbalances when he needs to punctuate reality in terms of right and wrong, victim and
villain, actor and reactor, in spite of his knowing that all the comings and goings in the family are regulated by
homeostasis, and that each person obliges with his and her own contribution; because the therapist also knows
that an equitable distribution of guilt’s and errors would only confirm the existing equilibrium and neutralize
change potentialities.
While unbalancing is admittedly and necessarily unfair, it is not arbitrary. Diagnostic considerations dictate the
direction of the unbalancing. In the case of our example, the consultant chooses to support the husband rather
than the wife because in so doing he is challenging a myth that both spouses share: initially the husband agrees
to his wife’s depiction of him, and it is only through the intensity of the consultant’s message that he begins to
challenge it. At different points in the same session, the consultant supports the wife as a competent mother and
questions the idea of her unremitting inefficiency—
again, a myth defended not only by her husband but by herself as well. In the last analysis unbalancing—like the
entire structural approach—is a challenge to the system rather than an attack on any member..
LESSONS IN EFFECTIVE COMMUNICATION
If each member of the family is interdependent on other members of the family it stands to reason that
dysfunction with one will affect the whole. Effective communication is an important lessons that family systems
psychologist incorporate into group and individual family therapy sessions. To create an effective solution to
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any dysfunction or problem in the group dynamic requires effective communication so that all members of the
group or family are in touch with each other.
For example, the mother who commits to more and more tasks in order to compensate for her family's
overextending commitments may stretch herself to the limits because she lacks the ability to communicate how
stretched thin she is. Instead, she promises to do more and more, exerting increasing emotional and mental stress
upon herself when she cannot meet all the commitments she is making. This leads to disappointment and
disagreement in the family. When other members of the family express their disappointment, this impacts her
already damaged sense of self-worth leading to a vicious cycle that may result in depression, generalized
anxiety disorder, substance abuse and more. In every way, however, the family is not happy. Therapists teach
effective communication skills and the importance for mom to let the family know she is overextended and that
she either needs help or they need to rearrange priorities in order to break out of the circular causality of this
family's problems.
Effective communication allows a family to dialogue on their problems, concerns and feelings without lashing
out or feeling obligated to resolve the problems being shared. A large portion of effective communication
resides in active listening, a skill that must be learned.
EMOTIONAL CUT-OFF
Bowen's term for flight from an unresolved emotional attachment
Examples of emotional cut-off
A man refuses to speak to his sister for 15 years. The reason? At the time of their mother's death, he was
left alone to care for her as she died. Then, to add insult to injury, her sister questioned his family
loyalty.
After years of criticism and rejection, a wife decides not to speak to her in-laws anymore, a decision that
causes chronic problems in her marriage.
The child of a close-knit family moves across the country and only communicates with the family
through greeting cards on holidays.
Emotional cut-off is a process in which one or both parties in a relationship effectively terminate that
relationship in response to uncomfortable feelings between them. It's not uncommon within families.
To understand emotional cut-off it is necessary to understand the concept of emotional fusion.
Fusion has to do with the degree of emotional reactivity that exists between people.
If our reactivity to each other is so powerful that I cannot define and hold my own position as a self in our
relationship, I might feel I need to "cut-off" in order to feel functionally independent.
If my feelings in reaction to you are intense and unpleasant enough, I may "cut-off" from you rather than
dealing with my own strong feelings. Once I am "cut-off" from you, I no longer feel I have to deal with our
relationship. It relieves my anxiety.
The problem with emotional cut-off is that it is a short-term solution, which creates a long-term problem. People
grow, emotionally, through working out relationship hassles. In the process, they achieve "differentiation," the
polar opposite of fusion.
First, I can tell the difference between me and you. I don't have to react blindly to things you do or say. I am
myself and don't mind saying so. Second, I can differentiate my emotions from my reason. I can choose my
responses rather than reacting automatically (blindly). This is maturity: differentiating self from other;
differentiating emotion from reason.
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Emotional cut off can have the illusion of appearing like differentiation. They are similar in that a person is
realizing that their thoughts and feelings are different from their families. However, the difference is that people
who are emotionally cut off are no longer connected. The classic example of emotional cut off is the family
member who moves to another state or country just to “get away from his crazy relatives.” While this may seem
on the surface like maturity, is actually not as mature as being able to maintain that same sense of separateness
while remaining in contact with one’s family. The truly differentiated person is not so threatened that they need
to travel hundreds of miles away and change their phone number in order to maintain their separateness. They
are able to be around those who think and feel differently, while not being negatively affected. I believe that
emotional cut off is sometimes a precursor to differentiation. Sometimes it is easier to be comfortable “at home”
after going away and having and “away home” experience. (Brent Henrikson)
THE EMPTY CHAIR
The empty chair technique, most often utilized by Gestalt therapists (Perls, Hefferline, & Goodman, 1985), has
been adapted to family therapy. In one scenario, a partner may express his or her feelings to a spouse (empty
chair), then play the role of the spouse and carry on a dialogue. Expressions to absent family, parents, and
children can be arranged through utilizing this technique.
ENACTMENT
The process of enactment consists of families bringing problematic behavioural sequences into treatment by
showing them to the therapist a demonstrative transaction. This method is to help family members to gain
control over behaviours they insist are beyond their control. The result is that family members experience their
own transactions with heightened awareness. In examining their roles, members often adapt new, more
functional ways of acting.
FAMILY CHOREOGRAPHY
In family choreography, arrangements go beyond initial sculpting; family members are asked to position
themselves as to how they see the family and then to show how they would like the family situation to be.
Family members may be asked to re-enact a family scene and possibly re-sculpt it to a preferred scenario. This
technique can help a stuck family and create a lively situation.
FAMILY CONTRACT
The family contract is a therapeutic tool that allows families to negotiate terms and come to an agreement on
how they want to handle future family problems and to commit to positive change. A family contract, for
example, may detail that a child who copes with an eating disorder commits to talking about her feelings on
weight, eating and social perception. Her parents will then commit to listening and not dismissing her feelings.
All parties commit to working together to build self-esteem and a healthy lifestyle.
Family contracts are a positive tool in the arsenal of a family systems psychologist because they are facilitated
agreement that a family makes to avoid future dysfunction. The family contract also helps family members
recognize when problems are occurring, particularly if elements of the contract are not being upheld. Effective
family therapy techniques treat the entire family as an emotional unit of which each family member is a part of
and acknowledges that what affects one member of the family affects the whole family. By treating the whole
family as a unit, the family also becomes a part of the solution.
FAMILY COUNCIL MEETINGS
Family council meetings are organized to provide specific times for the family to meet and share with one
another. The therapist might prescribe council meetings as homework, in which case a time is set and rules are
outlined. The council should encompass the entire family, and any absent members would have to abide by
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decisions. The agenda may include any concerns of the family. Attacking others during this time is not
acceptable. Family council meetings help provide structure for the family, encourage full family participation,
and facilitate communication.
FAMILY FLOOR PLAN
The family floor plan technique has several variations. Parents might be asked to draw the family floor plan for
the family of origin. Information across generations is therefore gathered in a nonthreatening manner. Points of
discussion bring out meaningful issues related to one's past.
Another adaptation of this technique is to have members draw the floor plan for their nuclear family. The
importance of space and territory is often inferred as a result of the family floor plan. Levels of comfort between
family members, space accommodations, and rules are often revealed. Indications of differentiation, operating
family triangles, and subsystems often become evident. Used early in therapy, this technique can serve as an
excellent diagnostic tool (Coppersmith, 1980).
FAMILY LIFE CYCLE
Stages of family life from separation from one's parents to marriage, laving children, growing older, retirement,
and, finally, death.
Jjust like an individual, a family has developmental tasks and key (second-order) transitions like leaving home,
joining of families through marriage, families with young children (the key milestone, and one that initiates
vertical realignment), families with adolescents, launching children and moving on, families in later life. Key
question: "How well did the family do on its last assignment?" Horizontal stressors are those involving these
transitional assignments; vertical stressors are transmitted mainly via multigenerational triangling. Symptoms
tend to occur when horizontal and vertical stressors intersect. Divorce adds extra developmental steps for all
involved families.
Carter and Mcgoldrick elaborated the family life cycle
a. Leaving home
b. Joining of families through marriage
c. Families with young children
d. Adolescence
e. Launching children and moving on
f. Families in later life
FAMILY PHOTOS
The family photos technique has the potential to provide a wealth of information about past and present
functioning. One use of family photos is to go through the family album together. Verbal and nonverbal
responses to pictures and events are often quite revealing. Adaptations of this method include asking members
to bring in significant family photos and discuss reasons for bringing them, and locating pictures that represent
past generations. Through discussion of photos, the therapist often more clearly sees family relationships,
rituals, structure, roles, and communication patterns.
FAMILY SCULPTING
Developed by Duhl, Kantor, and Duhl (1973), family sculpting provides for recreation of the family system,
representing family members relationships to one another at a specific period of time. The family therapist can
use sculpting at any time in therapy by asking family members to physically arrange the family. Adolescents
often make good family sculptors as they are provided with a chance to nonverbally communicate thoughts and
feelings about the family. Family sculpting is a sound diagnostic tool and provides the opportunity for future
therapeutic interventions.
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An activity in which family members place themselves in postures symbolic of the family dynamics.
Satir placed people in position herself to activate right-brain experiencing.
FAMILY SYSTEM STRATEGIES
A family operates like a system in that each member's role contributes to the patterns of behaviour that make the
system what it is. Certain therapy techniques are designed to reveal the patterns that make a family function the
way it does. The tracking technique is a recording process where the therapist keeps notes on how situations
develop within the family system. Interventions used to address family problems can be designed based on the
patterns uncovered by this technique. Family sculpting is another technique that's used to realign relationship
patterns within the group. Members are asked to physically arrange where they want each member to be in
relation to the others. This technique provides insight into relationship conflicts within the family.
THE GENOGRAM
One of the best ways to begin therapy and to gain understanding of how the emotional system operates in your
family system is to put together your family genogram. Studying your own patterns of behaviour, and how they
relate to those of your multigenerational family, reveals new and more effective options for solving problems
and for changing your response to the automatic role you are expected to play.
The genogram, a technique often used early in family therapy, provides a graphic picture of the family history.
The genogram reveals the family's basic structure and demographics. (McGoldrick & Gerson, 1985). Through
symbols, it offers a picture of three generations. Names, dates of marriage, divorce, death, and other relevant
facts are included in the genogram. It provides an enormous amount of data and insight for the therapist and
family members early in therapy. As an informational and diagnostic tool, the genogram is developed by the
therapist in conjunction with the family.
GOAL SETTING
Start small — “What will be the first sign that things are moving in the right direction?” Goals must be
concrete.
ICEBREAKER COMPLIMENT OR POSITIVE STATEMENT
Generally speaking, when therapy begins with an involuntary client, one tool that is worth employing as a
matter of course involves the use of an icebreaker compliment or positive statement. The creative use of an
appropriate remark in the form of a compliment or some kind of positive statement to the client can go a long
way in easing tension in the client. It is considered creative when it requires the counselor to immediately
incorporate incidental elements in an appropriate and credible context for a compliment directed at the client; or,
it may simply state something positive to set the tone.
The contexts for the compliment or the positive statement may include:
• Relating situational factors, such as the client’s attendance or promptness for that day or the client’s care and
persistence in filling out the required office forms
• Thanking the client for coming to the session despite environmental factors such as the weather (good or bad)
and any other reasonably credible conditions relating to the client.
The icebreaker compliment or positive statement is deemed pre-emptive because the counselor delivers it at the
very beginning of the first session. It is poised and intended to make the client feel relaxed and welcomed.
Examples of Icebreaker Compliments or Positive Statements
- I’d like to thank you for getting here so promptly today. I do appreciate that very much.
- I’d like to thank you for taking the time to come in today.
- I’d like to thank you for filling out all those forms.
- I’d like to thank you for answering all those questions on the forms you filled out.
- I’d like to thank you for coming in and giving me the time to go over some things with you.
- I’d like to thank you for coming on time today on such a gloomy (or gorgeous) day.
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IDENTIFICATION
Family therapy techniques are used with individuals and families to address the issues that effect the health of
the family system. The techniques used will depend on what issues are causing the most problems for a family
and on how well the family has learned to handle these issues. Strategic techniques are designed for specific
purposes within the treatment process. Background information, family structuring and communication patterns
are some of the areas addressed through these methods.
INFORMATION-GATHERING TECHNIQUES
At the start of therapy, information regarding the family's background and relationship dynamics is needed to
identify potential issues and problems.
1. The Genogram
The genogam is a technique used to create a family history, or geneology. Both the family and therapist
work to create this diagram.
2. Family Photos
Having family members bring in meaningful family photos is also a technique used to gather information as
to how each member perceives the others.
3. Family Floorplan
One other technique involves having family members draw up floor plans of their home. This exercise
provides information on territorial issues, rules, and comfort zones between different members.
INTENSITY
Intensity is the structural method of changing maladaptive transactions by using strong affect, repeated
intervention, or prolonged pressure. Intensity works best if done in a direct, unapologetic manner that is goal
specific.
INTERVENTION TECHNIQUES
Intervention techniques are directives given by the therapist to guide a family's interactions towards more
productive outcomes. Reframing is a method used to recast a particular conflict or situation in a less threatening
light. A father who constantly pressures his son regarding his grades may be seen as a threatening figure by the
son. Reframing this conflict would involve focusing on the father's concern for his son's future and helping the
son to "hear" his father's concern instead of constant demands for improvement. Another technique has the
therapist placing a particular conflict or situation under the family's control. What this means is, instead of a
problem controlling how the family acts, the family controls how the problem is handled. This requires the
therapist to give specific directives as to how long members are to discuss the problem, who they discuss it with,
and how long these discussions should last. As members carry out these directives, they begin to develop a
sense of control over the problem, which helps them to better deal with it effectively.
INVOLUNTARY CLIENT SHEMA
Citing original work done by Insoo Kim Berg (1990) together with Eve Lipchik regarding initial approaches in
dealing with involuntary clients, Walter and Peller present a useful involuntary client schema that reflects and
encapsulates the joint efforts of all four counselors.
Their collective work centers on the employment of a specific sequence of questions aimed at overtly clarifying
the relationship between the counselor and the involuntary client (or patient) at the outset of the first session
(Walter and Peller, 1992, pp. 247–253).
The purpose of this schema is to effect a transformation of the mindset of an involuntary client into that of a
voluntary client in the sense that the then-converted voluntary client may care to propose a goal which can
become the focus of therapy.
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Before proceeding with the illustration of the schema, a few conditions warrant consideration. If the therapist
does not succeed in negotiating this new mindset with the use of the schema, and if the involuntary client
chooses to remain the same (i.e., not establish a goal), and if the series of appointments must be continued
because of contractual arrangements (e.g., by the courts or by other agencies), then all the possible
consequences (the resulting constraints) will be explained to the client. One possible consequence may involve
the fact that future therapy sessions may be terminated by the therapist despite the existence of a contractual
agreement with outside agencies (courts). This factor often compels clients to rethink their position.
Even if the client is resistant to change and does not admit to the existence of a problem, there is hope that
during the session the client could have a change of heart and may want to discuss the problem and establish a
related goal.
The schema shown below illustrates the basic approach to changing the mindset of clients from an involuntary
to a voluntary status. Those questions posed by the therapist make reference to the person or agent who initiated
the request (or order) to have the client attend therapy. The initiator may be a spouse, a parent, or a court judge.
Walter and Peller’s schema is carried out with involuntary clients in the following manner.
Our work with them follows this schema:
- Whose idea is it that you come here?
- What makes think you should come here?
- What does want you to be doing differently?
- Is this something you want? (Goal frame)
If yes, proceed as with a voluntary client.
If no, ask: Is there something you would like out of coming here? (Goal frame)
- If yes, proceed as with a voluntary client.
- If no, explore the consequences of not coming to sessions.
Source: Walter, J. L., and Peller, J. E. (1992). Becoming solution-focused in brief therapy, 247. New York:
Routledge.
Carpetto and Peller suggest asking the client again “what the referring person expects out of the client coming in
for therapy.” If that is not clear, it should be clarified by seeking the specifics. Again, if the client still insists on
not abiding by the referring person’s goal, two options remain for the therapist: “say goodbye” to the client or
“state conditions for further sessions if continued sessions are required by the court or agency policy” .
In a nutshell, this is a flexible and effective general approach that will usually expedite the process of therapy.
Like all strategies, there is no guarantee that it will work in all cases.
Nonetheless, it is a highly recommended strategy because of the following considerations.
• It allows clients to think seriously about the decision to accommodate or not to accommodate the
referring person’s goal.
• It allows clients to consider what they want to get out of coming to therapy.
• It is particularly advisable as an initial approach because regardless of the outcome the client knows
the options from the outset.
• There are no hidden agendas, and a sense of collusion between the therapist and outside agencies or
family initiators is completely avoided.
• The process can help to pre-empt many unexpected problems from becoming greater problems. Even
if the sessions become difficult, the relationship between therapist and client at least had been
clarified and the options were plainly spelled out.
By contrast, therapists who attempt to treat involuntary clients as voluntary clients (i.e., like any other client) in
the initial session without the use of the schema (as presented by Walter and Peller or by a similar pre-emptive
strategy) will most likely find their difficulties intensified in conducting therapy. If such is the case, then the
therapist-client relationship in the initial and in forthcoming sessions may prove to be frustrating.
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After this initial strategy is employed with the involuntary client, the client may choose to become a voluntary
client. If that is the case, then any number of approaches, including those suggested in the prior chapter, are
readily available to begin the process of therapy, which would also include discussing the problem and
establishing a goal.
JOINING
This is the process of coupling that occurs between the therapist and the family, leading to the development of
therapeutic system. In this process the therapist allies with family members by expressing interest in
understanding them as individuals and working with and for them. In joining, the therapist becomes accepted as
such by the family, and remains in that position for the duration of treatment; although the joining process is
more evident during the initial phase of therapy, the maintenance of a working relationship to the family is one
of the constant features in the therapist’s job.
Joining is considered one of the most important prerequisites to restructuring. It is a contextual process that is
continuous. Much of the success in joining depends on the therapist’s ability to listen, his capacity for empathy,
his genuine interest in his client? dramas, his sensitivity to feedback. But this does not exclude a need for
technique in joining. The therapist’s empathy, for instance, needs to be disciplined so that it does not hinder his
ability to keep a certain distance and to operate in the direction of change. Contrary to a rather common
misunderstanding, joining is not just the process of being accepted by the family; it is being accepted as a
therapist, with a quota of leadership. Sometimes a trainee is described as “good at joining, but not at pushing for
change”; in these cases, what in fact happens is that the trainee is not joining well. He is accepted by the family,
yes, but at the expense of relinquishing his role and being swallowed by the homeostatic rules of the system.
Excessive accommodation is not good joining.
There are five ways of joining in structural family therapy.
1. Tracking:
In tracking, the therapist follows the content of the family that is the facts. Getting information through
using open-ended questions. Tracking is best exemplified when the therapist gives a family feedback on
what he or she has observed or heard.
According to Minuchin, tracking is where the therapist, “follows the content of the family’s
communications and behaviour and encourages them to continue… In its simplist form it means to ask
clarifying questions, to make approving comments, or to elicit amplification of a point.” (Minuchin (1974).
With maintenance the therapist’s message seems to be, “I see you, I support you in this, I validate you and
don’t judge”, in tracking the therapist’s message seems to be, “let me see if I am understanding
correctly…can you help me by clarifying that last thing you said”. Tracking lets the therpist check with the
family that she is understanding correctly, and at the same time she is allowing the family members to make
clearer and more explicit the implicit feelings and thoughts of the members. Tracking reminds me of
Roger’s idea of accurate empathy.
2. Mimesis:
The therapist becomes like the family in the manner or content of their communications.
According to Minuchin, “A therapist uses mimesis to accommodate to a family’s style and affective [feeling
range]. He adopts the family’s tempo of communication slowing his pace, for example, in a family that is
accustomed to long pauses and slow responses. In a jovial family he becomes jovial and expansive. In a
family with a restrictive style, his communication becomes sparse.” (Minuchin (1974)) The task with
mimesis is to join the family, to be engage in mutual acceptance with them. To be taking into the
confidences of a family in difficulty (or any family for that matter) and be of help requires a lot of trust.
Minuchin mentions that mimesis can happen without the awareness of the therapist as she endeavours to
“tune into” her client family. When I read about mimesis I thought of the concept of building rapport as
outlined in NLP.
3. Confirmation of a family member:
Using an affective word to reflect an expressed or unexpressed feeling of that family member.
4. Accommodation:
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The therapist makes personal adjustments in order to achieve a therapeutic alliance.
Joining and accommodation are two ways of describing the same process. Joining is used when
emphasizing actions of the therapist aimed directly at relating to family members or the familysystem.
Accommodation is used when the emphasis is on the therapist’s adjustment . . . in order to achieve joining.
To join a family system, the therapist must accept the family’s organization and style and blend with them.
(Minuchin, 1974, p.123)
Diagnosis in family therapy is achieved through the interactional process of joining. (Minuchin, 1974, p.
130).
Families like therapists accommodate to the other. A therapist “brings an idiosyncratic style of contacting,
and a theoretical set. The family will have to accommodate to this package, in some fashion or another, and
the therapist will have to accommodate to them. (Minuchin & Fishman, 1981)
In family therapy, a diagnosis is the working hypothesis that the therapist evolves from his experiences and
observations upon joining the family. This type of assessment, with its interpersonal focus, differs radically
from the process usually called diagnosis in psychiatric terminology. A psychiatric diagnosis involves
gathering data from or about the patient and assigning a label to the complex of information gathered. A
family diagnosis, however, involves the therapist’s accommodation to the family to form a therapeutic
system, followed by his assessment of his experiences of the family’s interaction in the present. (Minuchin,
1974, p. 129)
5. Maintenance
Maintenance is one of the techniques used in joining. The therapist lets himself be organized by the basic
rules that regulate the transactional process in the specific family system. If a four-generation family
presents a rigid hierarchical structure, the therapist may find it advisable to approach the great-grandmother
first and then to proceed downward. In so doing, the therapist may be resisting his first empathic
wish—perhaps to rescue the identified patient from verbal abuse—but by respecting the rules of the system
he will stand a better chance to generate a therapeutic impact.
However, in order to avoid total surrender the therapist needs to perform his maintenance operations in a
way that does not leave him powerless; he does not want to follow the family rule that Kathy should be
verbally abused whenever somebody remembers one of her misdoings. As with any other joining technique,
maintenance entails an element of challenge to the system. The therapist can for instance approach the
great-grandmother respectfully but he will say: “I am very concerned because I see all of you struggling to
help, but you are not being helpful to each other.” While the rule “great-grandma first” is being respected at
one level, at a different level the therapist is positioning himself one up in relation to the entire system,
including grandmother. He is joining the rules to his own advantage.
While maintenance concentrates on process, the technique of tracking consists of an accommodation of the
therapist to the content of speech. In tracking, the therapist follows the subjects offered by family members
like a needle follows the record groove. This not only enables him to join the family culture, but also to
become acquainted with idiosyncratic idioms and metaphors that he will later use to endow his directive
statements with additional power—by phrasing them in ways that have a special meaning for the family or
for specific members.
At times the therapist will find it necessary to establish a closer relation with a certain member, usually one
that positions himself or is positioned by the family in the periphery of the system. This may be done
through verbal interventions or through mimesis, a nonverbal response where the therapist adopts the other
person’s mood, tone of voice or posture, or imitates his or her behaviour -crosses his legs, takes his jacket
off, lights a cigarette. In most of the occasions the therapist is not aware of the mimetic gesture itself but
only of his disposition to get closer to the mimicked member. In other cases however, mimesis is
consciously used as a technique: for instance, the therapist wants to join the system via the children and
accordingly decides to sit on the floor with them and suck his thumb.
NORMALIZATION
Normalization is generally defined as a therapist’s use of indirect or direct statements that refer to client
problems not necessarily viewed “as pathological manifestations but as ordinary difficulties of life” (O’Hanlon
& Weiner-Davis, 1989, p. 93). The goal of this strategy is to pre-emptively depathologize client problems and
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the client’s view of the problems. However, normalization does not mean that criminal acts are honored,
approved, or condoned as being normal. Rather, normalization attempts to reframe client problem situations as
being understood as human. The normalization statement also contains the counselor’s implicit acceptance of
the client. It recalls Rogers’s sense of respect for the client and the client situation. In conducting psychotherapy
with people who have committed criminal acts, normalization occurs when the therapist accepts the ease with
which vulnerable people can fall into criminal patterns. It does not mean acceptance of the crimes.
Examples of Indirect Normalizing Statements
When therapists normalize the difficulties clients bring to therapy, clients seem relieved. Imagine the calming
effect when the “expert” appears unruffled by your description of the problem. This reaction influences clients
to think that perhaps things aren’t as bad as they had thought. This is an area where it is perhaps best to
communicate indirectly, by what is not said, by what one remains unruffled about. The most common way we
normalize during the session is to say things such as, “Naturally,” “Of course,” “Welcome to the club,” “So
what else is new?” and, “That sounds familiar,” when people are reporting things they think are unusual or
pathological. (p. 94)
More complicated than the indirect normalization and its typically implicit suggestion of understanding the
client situation, normalization can also take the form of a direct statement that may also be expressed as a
compliment. Direct normalization usually depends on incorporating material (content) that the client has just
related. The direct statement requires more work and creativity on behalf of the therapist. It also has a larger
overview, and it can be particularly effective and uplifting to the client when the therapist manages to find the
right wording and metaphors to deflate the emotional overlay of pathological fears the client may be
experiencing. In reality, normalization is a special form of reframe. Normalization, in effect, emphasizes human
qualities such as one’s vulnerability in experiencing problems in living (O’Hanlon & Beadle, 1997, p. 40).
The reality of the human condition involves experiencing reactions to those life events and situations that are
unforeseen or are simply normal transitions in the life cycle. To all losses, to all adjustments and changes, there
characteristically ensue conditions that are sometimes difficult and unmanageable. Unfortunately, self-blaming,
low self-worth, and poor support systems exacerbate these conditions. However, normalization may often
become a first step in lessening the impact of these negative reactions. Normalization can offer recognition (a
compliment) of the client’s efforts or persistence in coping with the problem (O’Hanlon & Weiner-Davis, 1989,
pp. 99–100).
Examples of Direct Normalizing Statements
• When the two of you tell me that you’re earning just above minimum wage and are working full-time and
raising five kids, I can’t help but admire your efforts at stretching the dollar so well.
• Given the fact that you lost everything you owned in the fire last year, I’m moved by your determination to
wait it out and do with what little you have right now until you receive the insurance money to rebuild.
Another Example of a Direct Normalizing Statement
Client: We’re having a rough time being a blended family. The kids resent him as my new husband.
Therapist: Maybe you expected there to be instant intimacy or closeness, or you hoped things would gel more
quickly. Most people find they have “lumpy” families for quite a while before they get blended (O’Hanlon &
Beadle, 1997, p. 40).
More Examples of Direct Normalizing Statements
Client: Since the divorce, the kids have been absolutely rebelling against everything and everybody. And that
includes me! I feel as if I’m the captain, and the crew is out to get me.
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Therapist: That’s often the case with teenagers when major life changes occur to them. It may mean sitting
down and plotting a new course with them.
Client: I really can’t see the sense of doing this anger management thing for the courts when I’ve been this way
all of my life. That’s my personality. That’s me! Ever since I can remember I’ve been this way.
Therapist: The fact that you can talk about that experience with such feeling and determination and that you’ve
been angry all of your life is the first step on the journey. Welcome to the program.
Normalizing client statements involves the therapist’s respecting and accepting the client and the client situation
and acknowledging the client’s humanity and the client’s struggles and frailties. In agreement with Maslow’s
philosophy, normalization focuses more on the acceptance of and empathy for human struggles and less on
pathology. While normalization downplays the pathological implications of the human situation, there is a
corresponding reframing that focuses on acknowledging the individual’s efforts and struggles in dealing with
human challenges. Again, normalization is a special kind of reframe, and as with all reframes, it is an attempt to
accommodate the client and hopefully join the client sooner.
OBSERVATION
Family units establish equilibriums to protect the family unit, but that equilibrium can cause an imbalance for
individual parts of the family. A clinical psychologist is trained to observed the family dynamic and monitor
both verbal and non-verbal cues. During the assessment phase and initial interviews, the family systems
psychologist will monitor how the parents interact with each other and how their children react to them. He or
she will compare his or her observations with testing data offered in both subjective and objective forms. The
subjective test data is gathered during the interview while the objective test data is gathered via clinical tests that
family members are requested to fill out and return to the psychologist.
Observation is an effective family therapy technique because it offers the psychologist the first real window into
the family dynamic. Family therapy may be recommended for any number of causes, but for the psychologist to
make a fair and accurate assessment, he or she must get a base measurement of the family's interactions,
emotional balance and initial dysfunction. During observation, for example, it may be revealed that a mother's
depression and need for anti-anxiety medication is due in part to her husband's unemployment and the economic
pressure she is overcompensating to fulfill. To create an effective treatment plan for the family, the therapist
needs as much data as possible.
POSITIVE CONNOTATION
Positive connotation, a term derived from the Milan School, is an approach combining reframing and joining
efforts whereby the therapist—after examining the family interactional patterns—ascribes worthy motives and
noble intentions to what otherwise might be considered only symptomatic behavior. In contrast to deframing,
which actively seeks to deconstruct useless beliefs, positive connotation seeks to reconstruct new possibilities
based on prior good intentions that were not realized. In essence, positive connotation deflates the symptomatic
dimensions of a problem while focusing on the potential stabilizing prospects of positive intentions, which are
sought because they demonstrate a more positive evaluation of family behavior. This tact serves as a means to
enter the family trust at the intentions level, uncharted territory where feuding or alienated family members
rarely travel. Thus exploring the intentions of family members can make the process of therapy more responsive
and effective (Simon, Stierlin, & Wynne, 1985).
Example of Positive Connotation in Referring to a Specific Family Member
An 8-year-old boy stopped doing well in school after the death of his grandfather. He also started talking and
acting like a caricature of a little old man. The boy insisted that his grandfather was following him when he took
walks with his father. The therapist stated to the boy, “I understand that you considered your grandfather to be
the central pillar of your family. Without your grandfather’s presence, you are afraid something would change,
so you thought of assuming his role, perhaps because you’re afraid the balance in the family would change”
(Sauber et al., 1993, p. 303).
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In the preceding example, it is important to note that the symptomatic behavior (i.e., doing poorly in school) is
not what is connoted as positive. What is key to understanding positive connotation is the ascribed intent
underlying the behavior that is connoted as positive, in that the child’s desire to perpetuate a sense of family
stability is personified in the figure of the grandfather. Positive connotation, in effect, deframes the strength and
power of the symptomatic behavior by ascribing good intentions as being present behind symptomatic
behaviors. Once the deframing is accepted, the therapist may proceed to process, for instance, how the other
family members present in the session feel about this perspective, the positive connotation.
Example of a Brief Amplification of a Positive Connotation
Father: At first, the new interpretation struck me as far-fetched: seeing the acting out and doing poorly
in school as connected to his desire to see the family remain in balance. I think I could stretch a little
and see it as some way fitting into the situation facing the family.
Therapist: How would all of you see it fit?
Mother: Well, I can see it fit very easily. My father-in-law is missed a lot by just about everybody. He
was well-liked and loved. And, I guess kids can be pretty complex creatures despite their age. I could
see how his acting and pretending to be his grandfather means he misses him a lot and misses all the
things he stood for.
T: What could be done?
F: I guess we can talk about my father, include him more in our conversation.
T: What are the kinds of things you’ll be saying?
M: We could say how much we miss him. We can talk about what he might have said or done about
things that come up in our lives.
F: We could visit the gravesite more often, bring flowers, and things like that.
For family members troubled by certain familial situations, positive connotation can often act as a catalyst,
helping family members to generate new ideas and new ways to handle problems. Positive connotation has the
capacity to do this because it can call into question — as deframing does — uncertain beliefs and perspectives,
but it can also serve to remove the negatively charged emotional overlay of symptomatic behaviors. It makes
this possible by introducing (within reasonable credibility) the possibility of good intentions on behalf of a client
and his or her intentions.
If deframing or positive connotation does not produce some practicable results, then other strategies can be
utilized. One such strategy is coping questions.
PARADOXICAL INJUNCTIONS
A paradox is an apparently sound argument which leads to a contradiction. It is used to motivate family
members to search or alternatives. Family members may defy the therapists and become better or they may
explore reasons why their behaviours are as they are and make changes in the ways members interact.
PRAGMATIC FICTIONS
Formal expressions of opinion to help families and their members change.
PRESCRIBING INDECISION
The stress level of couples and families often is exacerbated by a faulty decision-making process. Decisions not
made in these cases become problematic in themselves. When straightforward interventions fail, paradoxical
interventions often can produce change or relieve symptoms of stress. Such is the case with prescribing
indecision. The indecisive behaviour is reframed as an example of caring or taking appropriate time on
important matters affecting the family. A directive is given to not rush into anything or make hasty decisions.
The couple is to follow this directive to the letter.
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PROBLEM TRACKING
Problem tracking involves tracing past behavioral transactions for the express purpose of noting probleminteraction
sequences; however, problem tracking is not an end in itself. The use of problem-tracking
interactions goes back to the Mental Research Institute (Watzlawick, Weakland, & Fisch, 1974, pp. 110–115).
Postmodern therapy has since adopted the problem-tracking interaction strategy when it becomes necessary to
explore past interactive sequences. This strategy is often called into service when clients have difficulty
responding openly to basic questions or struggle to piece together the results of prior interviewing sequences.
Backtracking to past interactive behaviors that are related to the problem-maintaining patterns can offer notable
results. Problem tracking can often serve as a basis for returning to a present or future context for creating
solutions or dissolutions.
PROBLEM SOLVING TECHNIQUES
Problem solving is an effective therapy technique not because it teaches the family how to resolve the issue that
brought them to see the family systems psychologist, but it teaches them how to identify, develop plans and
create resolutions for future problems. Problem solving may seem like a common sense resolution, but it
requires a willingness on the parts of all parties to contribute to the solution.
Problem solving is a family therapy technique that requires effective communication and often comes later in
therapy sessions as the therapist challenges family members to role-play situations previously deemed
irresolvable. Family members may also be required to play the part of other family members, parents playing
the part of the children or dad taking on the role of mom to a child's dad and a mom's child. By actively role
playing other members of the family, each member is required to see that person's point of view. This leads to
learning how to disagree in positive and respectful manner and to not allow those disagreements to impede
problem solving efforts.
1. Dissolve the idea that there is a problem: Help people see their situations in new ways.
2. Negotiate a solvable problem: Reduce the size of the problem in the client’s eyes.
(Get specific about the problem; focus on when it is not so serious a problem).
3. Frame towards the idea that clients have all the abilities and resources to solve the problem:
Create an atmosphere that facilitates the realization of strengths and abilities.
PROBLEM DISSOLUTION
The point in the course of therapy when the client readily admits that the problem no longer exists and it
becomes apparent that the problem has been dissolved. This positive scenario is usually brought about by the
deconstructive efforts of deframing, whose thrust progressively eliminates the original impact of the problem to
the point where the problem evolves into a non-issue. This kind of outcome can and does occur with regular
frequency among postmodernist therapists, because their strategies and perspectives downplay pathology and
emphasize wellness.
PUNCTUATION
Punctuation is “the selective description of a transaction in accordance with a therapist’s goals”. Therefore it is
verbalizing appropriate behaviour when it happens.
Punctuation: thinking that you cause what I say.
PUTTING CLIENT IN CONTROL OF THE SYMPTOM
This technique, widely used by strategic family therapists, attempts to place control in the hands of the
individual or system. The therapist may recommend, for example, the continuation of a symptom such as
anxiety or worry. Specific directives are given as to when, where, and with whom, and for what amount of time
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one should do these things. As the client follows this paradoxical directive, a sense of control over the symptom
often develops, resulting in subsequent change.
QUESTIONS
1. THE MIRACLE QUESTION:
Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would
you know? What would be different?
This type of question seems to make a problem-free future more real and therefore more likely to occur.
The therapist gives guidelines and information to help the client go directly to a more satisfactory future.
2. FAST-FORWARDING QUESTIONS
can be used when clients can’t identify exceptions or past solutions. Clients are asked to envision a future
without the problem and describe what that looks like. (The miracle question or a magic wand question). =>
“What will not would be different?”
3. THE EXCEPTION QUESTION:
Asks the client to focus on times when problem does not occur or has not occurred when they expected it
would. They may discover solutions they had forgotten or not noticed. The therapist might find clues on which
to build future solutions.
Example: “What is different about those times when things are working?”
4. STRATEGIC BASIC QUESTIONS:
For a strategic therapist two questions are basic: How is the symptom “helping” the family to maintain a balance
or overcome a crisis? How can the symptom be replaced by a more effective solution of the problem?
5. PROVOCATIVE QUESTIONS:
The therapist attempts to recreate typical family interactions and conversation through provocative questioning
techniques so that the problems can be presented and addressed accordingly. It also give family members a
chance to see how their interactions and responses can contribute to a dysfunctional situation.
6. SCALING QUESTIONS AND PERCENTAGE QUESTIONS
Scaling questions are tools that are used to identify useful differences for the client and may help to establish
goals as well. The poles of a scale can be defined in a bespoke way each time the question is asked, but typically
range from "the worst the problem has ever been" (zero or one) to "the best things could ever possibly be" (ten).
The client is asked to rate their current position on the scale, and questions are then used to help the client
identify resources (e.g. "what's stopping you from slipping one point lower down the scale?"), exceptions (e.g.
"on a day when you are one point higher on the scale, what would tell you that it was a 'one point higher' day?")
and to describe a preferred future (e.g. "where on the scale would be good enough? What would a day at that
point on the scale look like?")
A strategy using simple mathematical values in a relative way, typically from one to ten, where a client ascribes
a mathematical value to describe the level of intensity regarding an affect, a behaviour, a thought, or any other
related query. For instance, a therapist may ask, “On a range from one to ten, how painful was it for you at the
beginning of this session? With one being very painful and ten being no pain whatsoever.” If the client answers,
“one” to that question, the response implies that coming to therapy must have been a rather painful time for the
client. Scaling questions can also serve as a negotiating tool in which questions are posed in the form of
embedded commands.
percentage questions: Like scaling questions, may be employed as tools for both gathering information and for
negotiating conditions for change by posing questions as embedded commands. These include burrowing out
double descriptions from the mass of information in the problem situation, measuring progress once a trajectory
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of progress has been established, negotiating new growth along that trajectory, and goal-setting. The negotiating
process expands the possibilities toward building solutions or dissolving the problems.
7. EXCEPTION SEEKING QUESTIONS
Proponents of SFBT insist that there are always times when the problem is less severe or absent for the client.
The counsellor seeks to encourage the client to describe what different circumstances exist in that case, or what
the client did differently. The goal is for the client to repeat what has worked in the past, and to help them gain
confidence in making improvements for the future.
8. COPING QUESTIONS
Coping questions are designed to elicit information about client resources that will have gone unnoticed by
them. Even the most hopeless story has within it examples of coping that can be drawn out: "I can see that
things have been really difficult for you, yet I am struck by the fact that, even so, you manage to get up each
morning and do everything necessary to get the kids off to school. How do you do that?" Genuine curiosity and
admiration can help to highlight strengths without appearing to contradict the clients view of reality. The initial
summary "I can see that things have been really difficult for you" is for them true and validates their story. The
second part "you manage to get up each morning etc.", is also a truism, but one that counters the problem
focused narrative. Undeniably, they cope and coping questions start to gently and supportively challenge the
problem-focused narrative.
coping questions are A strategy to explore what has occurred that is responsible for not making things get
worse; in other words, how family members have coped with the problem situation so that, at the very least,
things are the same and not worse. In explaining how things haven’t gotten worse, the clients usually allude to
something being done correctly, even if minimally. It is that kind of minor breakthrough that often allows the
therapist to expand upon the positive event that has actualized in the problem situation.
Potentially, that breakthrough can be a gateway to more positive developments, thus moving the therapeutic
conversation forward in search of more solutions toward resolving the problem or toward dissolving the
problem.
The strategy of coping questions could be employed in many areas of therapy, but it is particularly useful as a
tool with difficult clients. Often clients adamantly decline invitations to speak about the times in the past when
exceptions to their problem existed (i.e., periods of time when the problem was not present). They also can be
vehemently opposed to any therapeutic plan of action, which can be frustrating for the therapist. One possible
source for motivating the client to move forward in the therapeutic conversation is the introduction and use of
coping sequences. They are introduced by coping sequence questions.
Example of the Use of Introductory Coping Questions
With families that . . . do not respond well . . . I shift gears and mirror their pessimistic stance by asking them:
“How come things aren’t worse?”; “What are you and others doing to keep this situation from getting worse?”
Once the parents respond with some specific exceptions, I shift gears again and amplify these problem-solving
strategies and ask: “Howdid you come up with that idea!?”; “How did you do that!?”; “What will you have to
continue to do to get that to happen more often?” (Selekman, 1993, pp. 65–66)
The employment of a coping sequence involves exploring the problem at its present level of intensity and why
the problem has remained at that particular level. In short, why hasn’t it gotten any worse? In explaining how it
hasn’t gotten worse, the client usually alludes to something having been done right—even if minimally. It is that
kind of minor breakthrough that now allows the therapist to expand on the positive action that is actualized in
the problem situation. Potentially, that breakthrough can be a gateway to more positive developments, thus
moving the therapeutic conversation forward in search of more solutions toward resolving the problem or
toward dissolving the problem.
Example of a Coping Sequence
Therapist: What brings you here today?
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Client: Literally, my husband. He’s waiting outside. He’s been insisting I see a therapist.
T: How is it that he wants you to seek counseling?
C: Because he says I’m pretty much impossible to live with.
T: What is the specific nature of the situation that brought you here?
C: There’s no more communication. We barely speak the way we used to. Sex has become a sprint; there’s no
intimacy. We both have difficult jobs with long hours, and barely enough time to do anything.
T: How many years have you been married?
C: Five years. No kids. It’s just the two of us.
T: When did the situation start?
C: I see it as starting a year ago.
T: How long would he say the situation between the two of you has been going on?
C: That’s just it. He doesn’t realize there’s a problem with him. Everything is okay by him. Work, work, and
save money. That’s it in a nutshell. He started on that kick a year ago. Since then, we’ve done nothing else but
that. But he thinks there’s something wrong with me. That’s why he forced me to be here today. He’s got me
thinking that I’m going crazy.
T: I’m just very curious as to how come things haven’t gotten any worse?
C: He’s a good provider. He doesn’t run around. He has no vices, and he does love me.
T: So what else is there that has prevented things from getting any worse?
C: Well, we love our home. It’s in a gorgeous neighborhood. Our house should be paid off in about five more
years.
T: What else have you been doing so that things aren’t getting worse?
C: Well, two weeks ago, I got him to see a play downtown?
T: How important was that for you?
C: Very! It was the first time in ages that we actually spent money to see a play.
T: How did you get him to do that?
C: One evening, when he seemed cheerful, I just sat down with him. I said I really wanted to see this play with
him and he agreed. I was shocked. It seemed so easy.
T: So, it seems like something positive has already begun. How did you get that to happen?
C: Well, I told him how important it was for me. It was a play we had seen together when we were dating, and I
remembered that it was one of the few musicals he enjoyed. He normally hates musicals.
T: Sounds great. So what other changes do you think you might havestarted and not have realized until our
conversation today?
In the preceding example, the coping sequence questions did their job well. They accounted for the creation of a
new therapeutic context that in turn offered the possibility of a significant shift in direction in which other
forgotten or discarded solutions could come to the fore. In addition, other positive conditions could also be
pursued.
Once coping questions arrive at the level of recognizing patterned improvements, these patterns serve to confute
the client’s initially negative script, and the therapist could develop different strategies toward solution to the
client problem or toward dissolution of the problem.
As with all strategies, there are no guarantees, and coping sequences are no exception to that rule. When coping
sequences do not achieve success, a follow-up strategy of pessimistic questions may help bring the session
forward.
9. OPEN QUESTIONS
The therapist uses open-ended questions to get information. An open-ended question cannot be answered with a
simple "yes" or "no", or with a specific piece of information, and gives the person answering the question scope
to give the information that seems to them to be appropriate. Open-ended questions are sometimes phrased as a
statement which requires a response.
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Examples of open-ended questions:
Tell me about your relationship with your husband.
How do you see your future?
Tell me about the children in this photograph.
What is the purpose of this rule?
Why did you choose that answer?
10. PROCESS QUESTIONS.
The most common Bowen technique consists of asking process questions that are designed to get clients to think
about the role they play in relating with members of their family. Bowen's style tended to be controlled,
somewhat detached, and cerebral. In working with a couple, for example, he expected each partner to talk to
him rather than to talk directly to each other in the session. His calm style of questioning was aimed at helping
each partner think about particular issues that are problematic with their family of origin. One goal is to resolve
the fusion that may exist between the partners and to maximize each person's self-differentiation both from the
family of origin and the nuclear family system.
A Bowen therapist is more concerned with managing his or her own neutrality than with having the "right"
question at the right time. Still, questions that emphasize personal choice are very important. They calm
emotional response and invite a rational consideration of alternatives.
Examples of process questions:
A therapist attempting to help a woman who has been divorced by her husband may ask:
"Do you want to continue to react to him in ways that keep the conflict going, or would you rather
feel more in charge of your life?"
"What other ways could you consider responding if the present way isn't very satisfying to you and is
not changing him?"
"Given what has happened recently, how do you want to react when you're with your children and the
subject of their father comes up?"
Notice that these process questions are asked of the person as part of a relational unit. This type of questioning
is called circular, or is said to have circularity, because the focus of change is in relation to others who are
recognized as having an effect on the person's functioning.
11. LINEAR QUESTIONS
Direct linear questions can often be useful in gathering information from the system and clarifying information
given, especially at the beginning of therapy. Linear questions can be built up in a circular manner around the
family by asking different family members the same/similar linear questions.
Examples of linear questions:
How old are you?
Where do you go to school?
What do you do if you are upset?
What do you do after that?
12. CIRCULAR QUESTIONS
Circular questions are aimed at looking at difference and therefore are a way of introducing new information
into the system. They are effective at illuminating the interconnectedness of the family sub-systems and ideas. A
variety of circular questions may be used by the therapist as outlined in Table 2. These may be more or less
appropriate as therapy progresses.
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The use of particular types of circular questioning at different stages of the therapy will be highlighted
throughout the manual. The time scale of circular questions often changes fluidly between the past, present,
future.
Examples of circular questions:
About another’s state / behaviour / beliefs
What do you think John is feeling?
What do you think John is feeling when he shouts at you?
What ideas do you think John might have about that?
Offering alternative perspectives
What does John think of your school performance?
If I asked a teacher what would they say about it?
About relationships
direct : Do the girls really dislike each other?
indirect : How do the children react when they see you arguing?
Circular Definitions
When you and John raise your voices and Jill starts crying what does John do then?
Hypothetical and future-oriented questions
What will you think in 5 years time?
If you were to believe that attending to lifestyle changes would make a difference to your
cardiac condition, would that make you feel more inclined to quit smoking?
When you think about your health 5 years from now, what is your greatest concern?
Miracle question:
Imagine you woke up tomorrow morning and all the difficulties you were experiencing currently
had disappeared, how would things be different? What effect would that have upon your relationship
with x?
Ranking or Scaling Questions, also named “difference questions”:
Who is most likely to get upset when father is away, and who next is most upset?
Was there more communication between you before or after the heart attack last year?
On a scale of one to ten, how close do you think James and Sue feel when they argue?
Who worries the most about the angina attacks, your husband or yourself?
Behavioural effect questions:
When your husband tells you to stop working and rest during your angina attacks, what do you do?
When your husband shows that he is worried about you, what does that say to you and what effect
does that have on your own behaviour?
Triadic questions
If your daughter were here, what would she tell me about how the heart disease has affected
your relationship as a couple?
What would your husband say the physician's greatest concern about your health is at this time?
13. MONADIC, DIADIADIC AND TRIADIC QUESTIONS
Direct questions asked by a therapist to a client are called monadic questions.
Monadic denotes the number one (i.e., the client). “What is it like to be in jail?” is a monadic question.
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A therapist may also ask a client speculative questions such as what another person might think about the client
and client situation. Those questions are called dyadic because dyad refers to the number two: the client and
someone else.
If no headway is made with the use of monadic questions, a dyadic question will often serve as a strategic
manoeuvre to allow the client more psychological space to answer. The dyadic question, “What do you think
your wife felt about your being in jail?” involves two people: the client and his wife. In this case, the client will
probably be more apt to answer.
Similarly, a triadic question merely adds a third person to the dyad. The triadic question, “What do you think
your mother thought about your wife’s view of your being in jail?” involves three people.
Dyadic and triadic questions are clever means of making dialogue possible between therapists and reluctant
clients. When involuntary clients hesitate to talk about themselves, the therapists may find dyadic and triadic
questioning particularly helpful in gathering data.
Strategically, these questions often further distance the client from the painful immediacy of the situation by
“letting someone else” describe it.
The crucial importance of a dyadic or triadic question lies in the oblique manner a therapist is able to phrase
questions. It serves as an indirect route to access client data.
While there are no guarantees that clients will respond favourably to dyadic or triadic questions, clients who do
not care to answer questions about themselves are more likely to answer questions that are posed from an
oblique perspective.
These questions act as a bypass or a detour, cleverly couched and positioned as if the answers are coming from
the thoughts and feelings of other people. The client’s voicing of what others might believe and what others
might be saying or thinking paradoxically allows the therapist access into the client’s world. In effect, dyadic
and triadic questions permit the clients, on the one hand, to hide and partially protect themselves and, on the
other, to reveal the nature and quality of their interactive relationships.
Examples of Dyadic Questions
How does your wife feel about your drinking problem?
What do you think are your husband’s feelings about the affair you had?
How does your mother feel about your getting stopped for a DUI?
What does your father think about your being asked to leave college?
What would your favorite hero think about your actions?
Examples of Triadic Questions
What does your mother think about the way your wife feels about your drinking problem?
What would your mother think about your husband’s feelings about your affair?
What does your father think about your mother’s feelings about your getting stopped for a DUI?
How does your mother feel about your father’s thoughts about your being asked to leave college?
What would your father feel about your favorite hero’s thoughts about your actions?
When a client is responsive to dyadic or triadic questions, the therapist will usually ask more related questions.
In this instance, the questions could take the form of an amplification that would yield more in-depth
information. Here the therapist is definitely offered an opportunity to explore and learn about the client’s
cosmos.
Example of a Dyadic Question Followed by Amplification
Therapist: What does your father think about your being asked to leave college?
Client: He’s pissed, he’s real pissed at me.
T: How did he show that?
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C: He said that if I didn’t go to therapy, he’d take the car away from me. And the car is under his name.
I’m not 18 yet. I won’t be for another seven months. I started college a year early. I was in a special
program in high school.
T: Wow, so you’re a year ahead of most high school students your age. Could you tell me how you
achieved that?
The client in the above scenario had initially been reluctant to talk about himself when the therapist employed
monadic questions, but when asked a dyadic question, he responded with little hesitation. Generally speaking,
reluctant clients are more apt to answer dyadic questions because they are probably perceived as less
troublesome. Surely there are many operative reasons why clients find them easier to respond to, and those
reasons vary from person to person. As is often the case, the client most likely found little difficulty acting as
“spokesman” for his father’s “thoughts and feelings.”
When dyadic and triadic questions fail to achieve success with involuntary clients, another strategy,
“normalization”, should be considered.
14. PESSIMISCTIC QUESTIONS
A strategy wherein the therapist joins the pessimism of the client and creates a new context from which the
therapist can launch questions of a different kind that might prove to be more effective than the prior coping
questions.
Strategically, pessimistic sequence questions can often evoke client response because pessimistic questions gain
their strength by yielding to an anticipatory sense of worsening client scenarios.
The therapist’s joining clients in their worsening situation helps to create a reverse psychology scenario where
the therapist—now one of them, so to speak—suggests pre-emptively a kind of hopelessness that ironically the
client might best handle with a positive activity.
The strategy of pessimistic questions involves the therapist’s joining the pessimism of the client(s). As a tactic,
it allows the therapist to launch questions of a different nature, which might prove to be effective almost
immediately in some cases.
Strategically, pessimistic questions can be effective in evoking client responses because these questions gain
their strength by yielding to an anticipatory sense of worsening client scenarios. In effect, the therapist’s act of
joining clients in their worsening situation helps to create a reverse psychology scenario where the
therapist—now being one of them, so to speak—is suggesting pre-emptively a kind of hopelessness that,
ironically, the client might best handle with some kind of positive activity.
Example of the Use of Introductory Pessimistic Questions
Often this line of questioning will enable family members to generate some useful problem solving and coping
strategies to better manage their difficult situation.
Typical examples of pessimistic questions are as follows:
“What do you think will happen if things don’t get better?”;
“And then what?”; “Who will suffer the most?”; “Who will feel the worst?”; “What do you suppose is the
smallest thing you could do that might make a slight difference?”; “And what could other family members do?”;
“How could you get that to happen a little bit now?” (Selekman, 1993, p. 72)
Example of a Pessimistic Question Sequence
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Therapist: You seem to be telling me that at home things went from bad to worse. If things don’t get better
now, what do you think will happen?
Client: She’ll pick up and leave. (pause).
T: And then what?
C: It’ll be a real mess then, because she knows I love her. We both had a drug habit, but now she’s clean, but
I’m not. (pause).
T: Who will suffer the most if she leaves?
C: I will.
T: In what way?
C: I don’t want her to leave. I love her too much for her to leave. It’s a cruel world out there. I like her a lot, and
she knows that. We had plans to get married. I want her to be my wife. I’m not looking for other women.
T: And so, what do you suppose is the smallest thing you can do to make things just a little bit better, however
slight?
C: I’d say I’d have to go cold turkey.
T: What makes you say that?
C: Because that’s how she did it.
T: And?
C: She’ll expect me to do the same thing.
T: Do you know that for sure?
C: She told me so.
T: How did she go cold turkey?
C: Willpower. She’s a pretty strong person.
T: What do you suppose could be done in your situation?
C: I guess I’d have to ask her for help.
T: In what way?
C: I don’t know. Maybe I can ask her for some ideas.
T: What made you think of asking her for some ideas?
C: I don’t know . . . just an idea I had.
T: It’s not just an idea. It’s a great idea. What made you think of that?
C: Well, she’s resourceful.
T: In what ways do you think she’ll be resourceful when you ask her?
C: Maybe she’ll come up with ways that’ll help me cope with going cold turkey.
T: I bet you know some of those things already.
C: Yeah, I noticed some of the things she did.
T: Could you mention some of them?
The main objective of pessimistic sequences is to assist the individual client, a couple, a family, or anyone in a
relationship to come up with new ideas or to recall successful strategies (exceptions) from their respective pasts.
Once new ideas or tried-and-tested exceptions from the past are accessed and amplified, they in turn help to
generate not only coping skills in the present but also major creative ways to solve problems. That is the essence
of pessimistic sequences.
Clients may be so entrenched in their problems that pessimistic sequences and coping sequences have little or
no affect on them. In this case, the strategy of problem-tracking sequences can be tried. Problem tracking can be
used as a new introductory strategy that serves to discover new contexts by starting at the rock bottom of
fundamentals, namely, the interactive patterns (the behaviors) that maintain the problem situation (Selekman,
1993, pp. 76–77).
15. PROBLEM TRACKING QUESTIONS
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Tracing past behavioral interactions for the express purpose of noting problem interaction sequences; however,
problem tracking is not necessarily an end in itself. This strategy is often called into service when clients have
difficulty responding openly to basic questions or when they struggle to piece together the results of prior
interviewing sequences. Backtracking to past interactive behaviors relative to problem-maintaining patterns can
offer notable results. It can often serve as a basis for returning to a present or future context for creating
solutions.
Examples of Problem-Tracking Questions
“If you were to show me a videotape of how things look when your brother comes home drunk, who confronts
him first [asking a sibling of the identified client], your mother or your father?”; “After your mother confronts
him, what does your brother do?”; “How does your brother respond?”; “Then what happens?”; “What happens
after that?”
Ideally the brief therapist will secure a detailed picture from the family members regarding the specific family
patterns that have maintained the presenting problem. (Selekman, 1993, pp. 76–77)
In the next example, a consultant was asked for a one-time consultation in an ongoing treatment with a family
that suffered from an unyielding problem concerning the children’s “unmanageable, disruptive behavior.” The
heart of the consultation interview consisted of about 10 questions, which have been condensed into the
following outline.
Example of a Problem-Tracking Sequence
Therapist: The children are both equally disruptive, or is one more disruptive than the other?
Client: Both equally.
T: Disruptive outside the house mostly, or inside, or both?
C: Only in the house.
T: I see. At any particular time or circumstance?
C: During dinner.
T: So, what happens?
C: Well . . . [Goes on to explain details of escalating disruption.]
T: And then who tries to stop this?
C: Mother.
T: What does she do?
C: [Goes on to explain mother’s failing attempts at control.]
T: And while this is going on between mom and the kids, what is father doing?
C: At first father doesn’t do anything, but then when it gets loud enough he yells from the bedroom and then
things settle down.
T: Excuse me, father is not at table?
C: No, father is bedridden.
T: Why is that?
C: He has cancer.
T: I see. For how long has he been bedridden?
C: Two months.
T: For how long has this disruption been a problem?
C: Two months. (Real, 1990, p. 265)
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When affect and cognition are difficult to ascertain, problem tracking becomes a key strategy. This helps
explain the key role that problem tracking plays especially when dealing with reluctant clients or with clients
who present many difficulties.
Problem Tracking and its Pivotal Position.
In general, when therapeutic strategies do not seem to be working effectively, the strategic use of problem
tracking may jump-start the therapeutic process. It may bring to light the problem-maintaining sequences of
familial interactions (i.e., negative or unwanted behaviors that perpetuate themselves). However, once those
unwanted interactive behaviors are examined in the therapeutic process, the palpable knowledge of their
existence may often become the basis for the generation of new kinds of questions that may lead to the
successful resolution of the client problem.
Because problem-tracking sequences are often able to overcome client reluctance to engage in dialogue, they
acquire pivotal positions from which many other therapeutic strategies may be launched in the resolution of
problems.
Integrative Options
Once problem tracking has proved to be successful in disarming client reluctance or client resistance (when
prior strategies weren’t able to do so), this becomes an opportunity to revisit and utilize prior strategies. While
problem tracking is useful by itself (examination of behavioral interactions), it acquires more worth by being a
conduit to other strategies and allowing them to perform their functions. Once problem tracking has performed
its job, the therapist—in an integrative format—may return any number of strategies.
When the problem-tracking strategy overcomes a roadblock in the process of interviewing, many strategies
become available. The therapist has immediate access to a host of strategies, such as the ones discussed in prior
chapters (for instance, utilization, dyadic/triadic, normalization, deframing, coping, and pessimistic sequences).
In addition, therapists may also employ other prominent strategies such as those listed below.
• Exception-oriented questions
• Miracle question sequence
• Problem dissolution.
The problem dissolution strategy seems to be underutilized, yet it constitutes one of the typically important
postmodernist strategies.
16. CONVERSATIONAL QUESTIONS
In a sense, a deep return to eliciting basics, and a major resourceful strategy when clients are reluctant to
discuss their affect, behavior, and cognition. It has been found to be particularly useful with “highly entrenched
and traumatized families” and in cases where there are “family secrets.” It embodies a special tripartite
therapeutic focus on employing a not-knowing attitude, a unique therapeutic focus on posing questions based on
a profoundly elemental sense of curiosity, and a healthy introduction of uncertainty.
if the therapist has not had success with problem tracking sequences, circular questioning, or externalization of
the problem, then the therapist may proceed with conversational questions. When clients are reluctant to discuss
affect, cognition, and especially behavior (problem tracking), conversational questions can become a major
strategy. This option has been found to be particularly useful, for instance, with “highly entrenched and
traumatized families” and in cases where there are “family secrets” (Selekman, 1993, pp. 77–79).
Conversational questions allow the use of dialogical choices that usually involve returning to eliciting basics,
with a postmodernist twist. The questions embody a special therapeutic focus that employs a not-knowing
attitude and, similarly, a unique therapeutic focus on posing questions. The strategy is based on a profoundly
elemental sense of curiosity as professed by Anderson and Goolishian in the espousal of their conversational
approaches that emphasize a high collaborative relationship with the client.
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The therapist thereby establishes an open-ended agenda that requires starting from a new beginning. The process
is akin to starting at the origin of the client reason for being there and a host of general questions that encourage
clients to talk, dialogue, and interact verbally in the session. Nothing is taken for granted. Clients are
encouraged to speak freely about their situation, what brought them there, and virtually anything else that is on
their minds that seems important at the moment. Despite whatever feelings of discomfort clients may experience
on this therapeutic turf, conversational questions as a strategy help create the new conditions for a fresh start.
Conversational questions maintain effectiveness not only because of the engaging attitude of the therapist, but
also because of the quality and substance of well-chosen questions.
Clients might be asked about what kinds of questions they felt the therapist should have or could have
previously asked in the session (but didn’t); or about what kinds of things prior therapists did that could have
been done differently or better; or what they did that was totally useless and ineffectual. In all, this strategy
constitutes an elemental therapeutic process of entering and expanding the areas of the unsaid or the not-yet-said
(Anderson & Goolishian, 1988, p. 381).
This unique process of questioning might be compared to a metaphoric rite of passage.
Once therapists are offered privileged access into this once uncharted and inviolable precinct, they may find that
it contains a painful family secret, a dilemma that seems uniquely impenetrable to clients, or simply a difficult
situation that appears to be not easily discussed at the moment.
The following six conversational questions are examples taken from Selekman’s work. They offer a rich flavor
of the kinds of questions that therapists can ask to insure the certainty of this new openness with its
unquestionably “non-agenda” agenda condition. From an integrative perspective, it is an all-out approach at
loosening up and breaking through familial barriers and through the mountainous accumulation of family
members’ failed attempts at dealing with their issues in order to reach family members who now may feel all the
more stymied in the throes of therapy.
Examples of Conversational Questions
You have seen many therapists. What do you suppose they overlooked or missed with you?
If I were to work with another family just like you, what advice would you give me to help that family out?
Who had the idea in the family to go for therapy?
If there were one question you were hoping I would ask, what would that be?
If there were one issue in this family that has not been talked about yet, what would that be?
Who in the family will have the most difficult time taking about this issue? (Selekman, 1993, p.78)
Who probably had the most difficult time coming here today?
What is one major thing holding everyone back?
What is one major reason for not talking together as a family?
What are some things I should be asking about you?
If you’ve been to other therapists, what are some of the things you didn’t like about the questions they asked
or how they asked the questions?
What do you think are some needs that we should discuss first, before moving forward?
What did you like or dislike about your prior therapists?
What people in the family could change things if they had the power?
What people do you trust the most? Why is that so?
What is one small thing that could be changed to help get us started today?
In sum, the use of conversational questions may be a major tool when a client or an entire family is reluctant to
speak openly or when the therapeutic dialogue comes to a grinding halt. It is the therapist’s hope that
conversational questions such as the ones above will create the new and necessary conditions for a more
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expanded focus and a continuance of the therapeutic conversation. Whenever breakthroughs occur in this
manner, it means that situational issues, family stories, family problems, and family secrets become acceptable
topics. This increases the possibility of bringing about therapeutic conversations.
17. FRAMING QUESTIONS
Questions asked can elicit information about strengths, abilities, and resources. Perceptions of problems then
change significantly in this context.
18. DEFRAMING QUESTIONS
Deframing effectively challenges the existence—or at least the power—of the problem (O’Hanlon & Weiner-
Davis, 1989, pp. 52–53). By introducing uncertainty and doubt into the client’s cosmos. It can be a powerful
tool for influencing the client when dealing with a client’s dysfunctional, useless embedded beliefs.
Examples of Deframing Questions
- How do you know that to be so?
- What makes you say that?
- How is that so?
- Where did you get that idea?
- On what basis have you reached that conclusion?
- What do you think is the origin of that belief?
- What is the foundation on which you rest your case?
- Did you ever have any doubts about those thoughts?
- Are you sure that’s accurate?
- What makes you so sure?
- What are the benefits in believing that?
- What influenced you to think along those lines?
- Why would you want to stick with that belief?
REFRAMING
Most family therapists use reframing as a method to both join with the family and offer a different perspective
on presenting problems. Specifically, reframing involves taking something out of its logical class and placing it
in another category (Sherman & Fredman, 1986). For example, a mother's repeated questioning of her
daughter's behaviour after a date can be seen as genuine caring and concern rather than that of a nontrusting
parent. Through reframing, a negative often can be reframed into a positive.
The technique of reframing is a process in which a perception is changed by explaining a situation in terms of a
different context. For example, the therapist can reframe a disruptive behaviour as being naughty instead of
incorrigible allowing family members to modify their attitudes toward the individual and even help him or her
makes changes.
REFRAMING PROBLEM DEFINITIONS
Solution Oriented therapists offer new, more workable problem definitions that are within the power of the
client and therapist to solve. They usually help the client reframe the problem definition to a more positive one
or listen for a hint of something in the client’s complaint that can be solved. This co-creates the experience that
the problem is solvable and the client has some ability to solve it.
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RESTRUCTURING
The procedure of restructuring is at the heart of the structural approach. The goal is to make the family more
functional by altering the existing hierarchy and interaction patterns so that problems are not maintained. It is
accomplished through the use of enactment, unbalancing, and boundary formation.
SHAPING COMPETENCE
The family therapists help families and individuals in becoming more functional by highlighting positive
behaviours.
USE OF SILENCE
A strategy that is generally used only after most other strategies have failed for one reason or another. Silence
can also be an effective tool at the beginning of a session, if the conditions warrant it. Pre-emptive tactics, such
as the involuntary client schema developed by Walter and Peller, are designed to encourage the client to
communicate openly, thereby avoiding the therapist’s use of silence. If the use of silence becomes necessary,
the therapist should inform the client of the reason and should make it clear that the client is welcome to speak
and begin a conversation.
The use of silence should not be confused with a pause in the interview process, which is intended to be
momentary. The pause serves to give the client time and psychological space to think especially if the
therapist’s question involves something painful. Silence, instead, is a strategy that brings the therapist’s
questions to a grinding halt. Silence may also be an effective tool at the beginning of the session if conditions
warrant it. For instance, if an involuntary client is totally nonresponsive and does not care to communicate at all,
then employing silence as a strategy at the beginning of the hour is understandable, though not usually the case.
In dealing with the involuntary client, early options should be presented that include the use of an interviewing
schema, such as the one discussed earlier by Walter and Peller, or any other pre-emptive tactic geared to
involuntary clients. When all attempts yield little or nothing and the therapist surmises that the client is
maintaining a silence even after being made aware of the consequences of not having future sessions, it may be
time for the therapist to introduce silence into the interview.
Before embarking on extended periods of silence, the therapist should inform the client that, for the time being,
silence will prevail only because there has been no real communication, but if the client cares to speak and begin
a conversation, that will be welcomed.
Once the strategy of silence is implemented, a staring contest will usually ensue.
Three Examples of Preparatory Statements Prior to the Use of Silence
Example 1
Therapist: So far we’ve spent about 30 minutes together, and you’ve said very little. We’ve already discussed
the consequences of your not coming to future sessions. Your parole officer or the court may decide to change
your status. I’ll remain quiet for a while, and whenever you feel you’d like to say something to get things going,
I’ll welcome your remarks.
Example 2
Therapist: So far we’ve spent about 20 minutes together, and you’ve said very little. We’ve already discussed
the consequences of your not coming to future sessions. Your spouse may decide to take action that may not
please you. I’ll remain quiet for a while, and whenever you feel you’d like to say something to get things
moving along, I’ll welcome your remarks.
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Example #3
Therapist: So far we’ve spent about 15 minutes together, and you’ve said very little. We’ve already discussed
the consequences of your not coming to future sessions. Your parents may decide to take action that may not
please you. I’ll remain silent for a while, and whenever you feel like saying something to get things moving
along, I’ll welcome your remarks.
Silence can function as a tool to negotiate a new beginning for the client-counselor relationship. By contrast,
this chapter, as a whole, invites the beginning counselor to examine a substantially rich foundation of versatile
strategies and to utilize them in an effective integrative manner in interviewing involuntary clients. The
involuntary client schema, a key protocol to be used at the beginning of the first session with involuntary clients,
was specifically designed to minimize possible roadblocks at the outset of the therapeutic process.
While accessing and utilizing effective integrative strategies, it is important to remember that the counselor’s
posture (attitude) is a major ingredient in establishing and maintaining a collaborative relationship with the
involuntary client.
Being able to enter the client cosmos and empathically understand the specifics of the client’s frame of
reference, especially client rationales and purported defenses, is one of the major keys to success. The following
extract corroborates what many postmodernist proponents have said all along.
The biggest lesson of my 25 years in this work is that when you align with the client’s defenses, you have
essentially removed the need for them. And it is only when the clients’ defenses soften—whether they are courtmandated
clients or self-referred—that they are able to take the first steps toward looking at themselves,
connecting with others and ultimately taking responsibility for their lives. (Borash, 2002, p. 22)
SPECIAL DAYS, MINI-VACATIONS, SPECIAL OUTINGS
Couples and families that are stuck frequently exhibit predictable behaviour cycles. Boredom is present, and
family members take little time with each other. In such cases, family members feel unappreciated and taken for
granted. "Caring Days" can be set aside when couples are asked to show caring for each other. Specific times for
caring can be arranged with certain actions in mind (Stuart, 1980).
WORKING WITH SPONTANEOUS INTERACTION
In addition to enactment, structural family therapists concentrate on spontaneous behaviours in sessions. It
occurs whenever families display behaviours in sessions that are disruptive or dysfunctional, such as members
yelling at one another or parents withdrawing from their children. The focus is on process not content. It is
important that therapists help families recognize patterns of interaction and what changes they might make to
bring about modification.
STRATEGIC ALLIANCES
This technique, often used by strategic family therapists, involves meeting with one member of the family as a
supportive means of helping that person change. Individual change is expected to affect the entire family
system. The individual is often asked to behave or respond in a different manner. This technique attempts to
disrupt a circular system or behaviour pattern.
TRACKING
The tracking technique is a recording process where the therapist keeps notes on how situations develop within
the family system. Interventions used to address family problems can be designed based on the patterns
uncovered by this technique
Most family therapists use tracking. Structural family therapists (Minuchin & Fishman, 1981) see tracking as an
essential part of the therapist's joining process with the family. During the tracking process the therapist listens
intently to family stories and carefully records events and their sequence. Through tracking, the family therapist
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is able to identify the sequence of events operating in a system to keep it the way it is. What happens between
point A and point B or C to create D can be helpful when designing interventions.
In tracking, the therapist follows the content of the family that is the facts. Getting information through using
open-ended questions. Tracking is best exemplified when the therapist gives a family feedback on what he or
she has observed or heard.
UNBALANCING
This is a procedure wherein the therapist supports an individual or subsystem against the rest of the family.
When this technique is used to support an underdog in the family system, a chance for change within the total
hierarchical relationship is fostered.
INTRODUCING UNCERTAINTY
The therapist can introduce some uncertainty into the problem definition by asking “What gives you the
impression that things seem difficult to handle?” Or he/she can imply that there are days when the problem is
nonexistent by asking “What is different about the days when things seem manageable?”
UTILIZATION STRATEGY
The utilization strategy, one of the most powerful Ericksonian strategies, is based on a simple concept. It
involves the therapist learning from the outset as many of the specific strengths and resources the client
possesses. This usually means asking clients questions that will evoke positive data. The therapist could then
process and integrate those data expeditiously in the early process and possibly accelerate the course of therapy.
Utilization may also include thoroughly exploring certain particulars of the client’s intake form, looking for
relevant particulars that, when incorporated in the process, could offer a possible winning combination in an
attempt to effectively enter a reluctant client’s cosmos. These particulars involve aspects of the client’s life
experience, attitudes, overall strengths and talents such as in the following:
• Work history in a particularly interesting or difficult job
• Interesting profession
• Challenging work experiences
• Hobbies
• Talents
• Interests
• Sense of humor
• Desire for change
• Positive attitudes
• Use of language
• Beliefs
• Intentions
• Narrative abilities
• General experiences.
Because Erickson pragmatically concluded from his studies that patients know (consciously and otherwise) their
strengths and resources best, he believed that it was natural for the therapist to utilize those strengths and
resources as early as possible, including those in the client’s “environmental” areas such as familial and
community relationships. In the therapeutic session, Erickson focused on utilizing patient strengths and
resources as a matter of course, not as remote theoretical options. Utilization has the immediate advantage of
not having to search elsewhere, especially in time-consuming excavational protocols.
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Example of Utilization Strategy
Therapist: I understand that you do artwork. Is that right?
Client: Yes. I do portraits at home and also commercial stuff.
T: Could you tell me about when you first started?
C: I always drew and doodled as a kid. Then, as a teenager, I discovered I could paint and get paid for it too. So,
it’s been about 20 years since I’ve been painting privately and working as a commercial artist.
T: What does your wife think about this talent that you possess?
C: She’s my biggest fan and, of course, my biggest critic.
T: How is she your biggest fan?
C: She supported and encouraged me in some of the lean years when my stuff wasn’t selling and when things
were slow and the commercial world gave me the pink slip. She was there whenever things got bad or I began to
doubt myself.
T: I’m just curious about something. How fast does your wife pick up on things in general?
C: I’d say pretty fast, but it all depends on what you’re talking about.
T: Does she pick up on how things are going in your life?
C: Yes. She’s pretty good at that. Yes, she is.
T: Do you have any examples as to when she definitely picked up on something, and it proved to be beneficial
to the two of you?
C: I was forced to stop work some years ago, and she picked up that I was prone to depression when things got
too stressful for me.
T: How did she help you then?
C: Well, at first, I fought her tooth and nail. (pause).
T: And, what else?
C: I guess I was stubborn.
T: How’s that?
C: I thought that depression just couldn’t happen to me, and so I fought all the way.
T: In what sense, all the way?
C: Denial. I denied all the way to the hospital. Things had gotten so bad that I started to drink. That was
something I didn’t usually do. I went into a stupor a couple of times, and the last time I did, she got frightened
and drove me to the emergency room. (pause).
T: What sense do you make of that event in your life?
C: She was right on the money.
T: How did it turn out?
C: I was only in the hospital for a few days. I was diagnosed with depression. Then I was discharged. While I
was there, they ran tests. They discovered that I also had a liver disease that I never knew about. If I had
continued drinking, I would have been dead a long time ago.
T: Have you had it checked out by your doctor since then?
C: Several times. My liver is doing fine.
T: That sounds like great news. I imagine you must be happy about that.
C: Yes, I am.
T: I understand your wife has some other concerns about you right now. Would you like to talk about them?
Before the preceding dialogue took place, the therapist had perused the client’s paperwork (intake). As in most
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intake forms, client attitudinal responses to intake questions vary. The answers to specific questions can often be
left blank, barely stated or understated, or sometimes even overstated. It is the therapist’s responsibility to read
and perhaps utilize any information that may offer the key to unlocking the door to the client’s world.
Prior to the therapy session in the preceding example, the therapist gleaned from the intake form some items that
could possibly offer easier access to the client’s cosmos. From these items, the therapist learned that:
• The client had identified himself as a commercial artist.
• He presented depression as the problem.
• He had prior psychiatric care.
• He had been requested by his wife to attend therapy.
• He was married for 15 years.
The therapist mingled these important factors and hypothesized that they could prove to be useful as a means to
enter the client’s cosmos as naturally as possible. The therapist attempted this by initially utilizing the client’s
talents as they might present an opportunity to both empower the client and join the client from the outset. Once
the session had begun, the therapist quickly utilized the apparent strengths possessed by both the client’s wife
and himself. These became the context and prelude to discussing the presenting problem.
This example illustrates how utilizing client information in the form of strengths and resources could effect a
jump-start in the initial interview of a client who is requested or ordered by the spouse to attend therapy.
However, as with any therapeutic attempts at entering the client’s world, they may fail to achieve the desired
results, and the therapist must move on to alternative strategies. When such is the case, dyadic and triadic
questions may be helpful.
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Summary of Family Therapy Theories &
Techniques
Theoretical Model Theorists Summary Techniques
Adlerian Family
Therapy
Attachment
Theory
Bowenian Family
Systems
Alfred Adler
John Bowlby, Mary
Ainsworth
Murray Bowen, Betty
Carter, Philip Guerin,
Michael Kerr, Thomas
Fogarty, Monica
McGoldrick, Edwin
Friedman, Daniel
Papero
Cognitive
John Gottman, Albert
Behavioral Family
Ellis, Albert Bandura
Therapy
Harry Goolishian,
Collaborative Harlene Anderson,
Language Systems Tom Andersen, Lynn
Hoffman, Peggy Penn
Also known as "Individual Psychology”.
Sees the person as a whole. Ideas include
compensation for feelings of inferiority
Psychoanalysis, Typical
leading to striving for significance toward a
Day, Reorienting, Re-
fictional final goal with a private logic. Birth
educating
order and mistaken goals are explored to
examine mistaken motivations of children
and adults in the family constellation.
Individuals are shaped by their experiences
with caregivers in the first three years of
life. Used as a foundation for Object
Relations Theory. The Strange Situation
experiment with infants involves a
systematic process of leaving a child alone
in a room in order to assess the quality of
their parental bond.
Psychoanalysis, Play
Therapy
Also known as “Intergenerational Family
Therapy” (although there are also other
schools of intergenerational family therapy).
Family members are driven to achieve a
balance of internal and external
Detriangulation,
differentiation, causing anxiety,
Nonanxious Presence,
triangulation, and emotional cut-off.
Genograms, Coaching
Families are affected by nuclear family
emotional processes, sibling positions and
multigenerational transmission patterns
resulting in an undifferentiated family ego
mass.
Problems are the result of operant
Therapeutic Contracts,
conditioning that reinforces negative
Modelling, Systematic
behaviours within the family’s interpersonal
Desensitization,
social exchanges that extinguish desired
Shaping, Charting,
behaviour and promote incentives toward
Examining Irrational
unwanted behaviours. This can lead to
Beliefs
irrational beliefs and a faulty family schema.
Individuals form meanings about their
experiences within the context of social
relationship on a personal and organizational
level. Collaborative therapists help families
reorganize and dis-solve their perceived
problems through a transparent dialogue
about inner thoughts with a “not-knowing”
stance intended to illicit new meaning
through conversation. Collaborative therapy
is an approach that avoids a particular
Dialogical
Conversation, Not
Knowing, Curiosity,
Being Public, Reflecting
Teams
279

Communications
Approaches
Contextual
Therapy
Emotion-Focused
Therapy
Experiential
Family Therapy
Feminist Family
Therapy
Milan Systemic
Family Therapy
Virginia Satir, John
Banmen, Jane Gerber,
Maria Gomori
Ivan Böszörményi-
Nagy
Sue Johnson, Les
Greenberg
Carl Whitaker, David
Kieth, Laura Roberto,
Walter Kempler, John
Warkentin, Thomas
Malone, August
Napier
Sandra Bern,
Luigi Boscolo,
Gianfranco Cecchin,
Mara Selvini Palazzoli,
Giuliana Prata
theoretical perspective in favour of a clientcentred
philosophical process.
All people are born into a primary survival
triad between themselves and their parents
where they adopt survival stances to protect
their self-worth from threats communicated
by words and behaviours of their family
members. Experiential therapists are
interested in altering the overt and covert
messages between family members that
affect their body, mind and feelings in order
to promote congruence and to validate each
person’s inherent self-worth.
Families are built upon an unconscious
network of implicit loyalties between
parents and children that can be damaged
when these “relational ethics” of fairness,
trust, entitlement, mutuality and merit are
breached.
Equality, Modeling
Communication, Family
Life Chronology,
Family Sculpting,
Metaphors, Family
Reconstruction
Rebalancing, Family
Negotiations,
Validation, Filial Debt
Repayment
Couples and families can develop rigid
patterns of interaction based on powerful
Reflecting, Validation,
emotional experiences that hinder emotional
Heightening,
engagement and trust. Treatment aims to
Reframing,
enhance empathic capabilities of family
Restructuring
members by exploring deep-seated habits
and modifying emotional cues.
Stemming from Gestalt foundations, change
and growth occurs through an existential
encounter with a therapist who is
intentionally “real” and authentic with
clients without pretence, often in a playful
and sometimes absurd way as a means to
foster flexibility in the family and promote
individuation.
Battling, Constructive
Anxiety, Redefining
Symptoms, Affective
Confrontation, Co-
Therapy, Humour
Complications from social and political
disparity between genders are identified as
underlying causes of conflict within a family
system. Therapists are encouraged to be Demystifying,
aware of these influences in order to avoid Modelling, Equality,
perpetuating hidden oppression, biases and Personal Accountability
cultural stereotypes and to model an
egalitarian perspective of healthy family
relationships.
A practical attempt by the “Milan Group” to
establish therapeutic techniques based on
Gregory Bateson’s cybernetics that disrupts
unseen systemic patterns of control and
games between family members by
challenging erroneous family beliefs and
reworking the family’s linguistic
assumptions.
Hypothesizing, Circular
Questioning, Neutrality,
Counter paradox
280

Medical Family
Therapy
MRI Brief
Therapy
Narrative Therapy
Object Relations
Therapy
Psychoanalytic
Family Therapy
Solution Focused
Therapy
Strategic Therapy
Structural Therapy
George Engel, Susan
McDaniel, Jeri
Hepworth & William
Doherty
Gregory Bateson,
Milton Erickson,
Heinz von Foerster
Michael White, David
Epston
Hazan & Shaver,
David Scharff & Jill
Scharff, James Framo,
Nathan Ackerman
Kim Insoo Berg, Steve
de Shazer, William
O'Hanlon, Michelle
Weiner-Davis, Paul
Watzlawick
Jay Haley, Cloe
Madanes
Salvador Minuchin,
Harry Aponte, Charles
Fishman, Braulio
Montalvo
Families facing the challenges of major
illness experience a unique set of biological,
psychological and social difficulties that
require a specialized skills of a therapist
who understands the complexities of the
medical system, as well as the full spectrum
of mental health theories and techniques.
Established by the Mental Research Institute
(MRI) as a synthesis of ideas from multiple
theorists in order to interrupt misguided
attempts by families to create first and
second order change by persisting with
“more of the same,” mixed signals from
unclear meta communication and
paradoxical double-bind messages.
Grief Work, Family
Meetings,
Consultations,
Collaborative
Approaches
Reframing, Prescribing
the Symptom,
Relabeling, Restraining
(Going Slow), Bellac
Ploy
People use stories to make sense of their
experience and to establish their identity as a
social and political constructs based on local Deconstruction,
knowledge. Narrative therapists avoid Externalizing Problems,
marginalizing their clients by positioning Mapping, Asking
themselves as a co-editor of their reality Permission
with the idea that “the person is not the
problem, but the problem is the problem.”
Individuals choose relationships that attempt
to heal insecure attachments from
childhood. Negative patterns established by
their parents (object) are projected onto their
partners.
De-triangulation, Co-
Therapy,
Psychoanalysis, Holding
Environment
By applying the strategies of Freudian
psychoanalysis to the family system
Psychoanalysis,
therapists can gain insight into the
Authenticity, Joining,
interlocking psychopathologies of the family
Confrontation
members and seek to improve
complementarity
The inevitable onset of constant change
leads to negative interpretations of the past
and language that shapes the meaning of an
individual’s situation, diminishing their
hope and causing them to overlook their
own strengths and resources.
Symptoms of dysfunction are purposeful in
maintaining homeostasis in the family
hierarchy as it transitions through various
stages in the family life cycle.
Family problems arise from maladaptive
boundaries and subsystems that are created
within the overall family system of rules and
rituals that governs their interactions.
Future Focus,
Beginner’s Mind,
Miracle Question, Goal
Setting, Scaling
Directives, Paradoxical
Injunctions, Positioning,
Metaphoric Tasks,
Restraining (Going
Slow)
Joining, Family
Mapping,
Hypothesizing, Reenactments,
Reframing,
281

Family Therapy Survey
Nichols and Schwartz (1998)
Unbalancing
282

I. The Foundations of Family Therapy - Outline by David Peers
A. The myth of the hero
1. The individual is unique and autonomous
2. Breaking free from childhood
3. The myth of rising above the human condition and individuation
4. Individuals are sustained by interpersonal relationships
5. Families are both withholding and uplifting - sometimes at the same time
B. Psychotherapeutic sanctuary
1. Therapy in isolation or in groups?
2. Freud and Rogers emphasized private patient/therapist relations
3. Freud: real family who needs it? The use of transference - the therapist as parent
4. Rogers: exploration of self and self - actualization. The need for approval
5. Rogers: support, unconditional positive regard, and the art of listening
C. Family vs. Individual therapy
1. Both are approaches to treatment and understandings of human behavior
2. Individual therapy
a. Concentrated focus
b. Internalization of personal dynamics
3. Family therapy
a. External focus
b. Changing organizations - change on the entire family, systemic
4. Are we separate entities or embedded in a network of relationships?
D. Psychology and social context
1. Family therapy flourishes because of success and recognition of interconnectedness
2. Is psychotherapy intrapsychic or interpersonal? Perhaps both or neither?
3. Family therapy as an orientation rather than a technique
4. Uncovering family influences
5. Individuals within a system
283

E. The power of family therapy
1. Evolution from 1950’s to today
2.1975 - 1985 as golden age - shared optimism and common purpose
3. Problems may originate from interaction so change focuses on interactions
4. Questions:
a. Constructivist notions?
b. Narrative therapy?
c. Integrative techniques?
d. Social issues?
F. Contemporary cultural influences
1. Managed health care
a. Crisis intervention versus ongoing personal exploration?
b. Confidentiality?. Prejudicial employers?
2. Postmodern scepticism
a. Integrated schools of thought
b. Approaches to clients or clients to approaches?
G. Thinking in lines vs. Thinking in circles
1. Cause and effect perspectives - unilateral influence
2. Circles of thought as empowering
3. Transforming interactions
4. Major advantage of family therapy: works directly on unhappy relationships
5. The difficulty of change
6. Personal participation in problems
7. Circular problems - the cause is the result and the result the cause
8. Learning life’s painful lessons and understanding the family’s story
284

II. The Evolution Of Family Therapy - Outline by Lori Rice
A. The undeclared war
1. 1950’s - - change in one person changes the system
2. Brown research with schizophrenic patients returning home (1959)
3. Current psychiatric hospital therapy and possible family segregation
B. Small group dynamics
1. William Mcdougall - group mind
2. Lewin - group is more than the sum of its parts - - group discussions superior to individual
instruction for changing ideas/behavior
3. Bion (1948) fight - flight, dependency, and pairing
4. Process/content in group dynamics
5. Role theories
6. Similarities between group and family therapies
C. Child guidance movement
1. Scholars publishing more than clinicians
2. Movement assumption: Emotional problems begin in childhood, therefore treat the child
3. Shift to include families in treatment, but typically blame parents for child’s problems
Fromm - Reichmann’s schizophrenogenic mother
D. The influence of social work
1. Family casework - families must be considered as units
2. Social workers among most influential in family therapy
E. Research on family dynamics and the etiology of schizophrenia
1. Gregory Bateson
a. Researched communication among animals
b. Functions of communication: report and command, metacommunication
c. Bateson joined by others to investigate conflicts between messages and
qualifying messages
d. Double bind
2. Theodore Lidz
3. Lyman Wynne - rubber fences, pseudomutuality, and pseudohostility
4. Role theorists marriage counseling
285

III. Early Models And Basic Techniques - Outline by Sarah Sifers:
Group Process And Communications Analysis
A. Family therapy has a history of being condescending
B. Sketches of leading figures
1. Group family therapy (group) - Bell, Dreikurs, Midelfort, Foulkes, Skynner
2. Communications family therapy (communication) - Jackson, Haley, Bateson, Satir
C. Theoretical formulations - group
1. Group/family leaders
2. Family defense mechanisms
3. Subgroups
4. Field theory (Lewin) - conflict is an ‘inevitable part of group life
5.Role theory - every group has roles that have "rules" for conduct (intra - and inter - role
conflict, fit between personality and role)
D. Theoretical formulations - communications
1. Black box - disregards individual complexity to focus on input and output (communication)
2. Circular causal (disregard past)
3. Syntax - - ways words are put together to make sentences
4. Semantics - clarity, private or shared communication systems, concordance versus confusion
5. Pragmatics - behavioral effects of communication
6. People are always communicating
7. Re ort - (content) conveys information
8. Command - statement about the definition of the relationship
9. Family rules - description of regular interactions
10. Family homeostasis - acceptable behavioral balance within the family
11. Complementary relationships - based on differences that fit together
12. Symmetrical relationships - based on equality and mirroring of behavior
13. Communication punctuation - organizes behavioral events and reflects observer bias
14. Negative feedback loop - perpetuates problems by maintaining status quo
15. Positive feedback loop - alters the system to accommodate novel input
286

E. Normal family development
1. Group
a. Instrumental and expressive leaders
b. Three phases of group development: inclusion, control, affection
c. Cohesiveness
d. Need compatibility
2. Communications
a. Feedback loops
b. Normal families become unbalanced during transitions in family life cycle
F. Development of behavior disorders
1. Group - symptoms as products of disturbed and disturbing group processes - if needs
continue to go unmet, symptoms may be perpetuated into a role and group organizes around a
"sick" member
2. Communications - "identified patient" as a role with counter roles and complimentary roles
that maintain the system - - - caused by pathological communication such as paradoxical
injunctions/ double binds
G. Goals of therapy
1. Group - individuation of group members, personal growth, and improved relationships
2. Communications - change/prevent maladaptive interactions viii.
H. Conditions for behavior change
1. Group - help family members talk to each other, concentrating more on process than content,
then explore those feelings
2. Communications - making covert messages behind symptoms overt. Therapist may
manipulate the family be prescribing the symptom or therapeutic double binds, introducing
positive feedback loops
I. Techniques of group family therapy
1. Therapist as process leader
2. Stages - child - centered, parent - centered, family - centered
3. Types of therapy - multiple group therapy, multiple impact therapy, network therapy
4. Resistance - anything that interfered with balanced self - expression
J. Techniques of communications family therapy
1. Structured family interview (5 tasks)
2. Teaching rules of clear communication - (using "I", stating facts, talking to - not about)
3. Used family’s moment to circumvent resistance
4. Therapist as referee and reframer, making implicit rules explicit and using therapeutic
paradox
287

K. Lessons from early models
1. Group - group dynamics, roles, process/content distinction, free and open discussion,
reflective interpretations, connective interpretations, reconstructive interpretations, normative
interpretations, networking, confronting, caveat - families aren’t egalitarian
2. Communications - double bind, meta communication, homeostasis, rules, feedback loops,
cybernetics, altering patterns of communication, paradoxical directives, symptoms - focused,
focus on marital pair
L. System’s anxiety
1. Therapists viewed family as being to blame for a "victim’s" illness and were, therefore, the
enemy
2. Cybernetics and general systems theory helped clinicians understand families, but tend to
dismiss selfhood as an illusion
M. Stages of family therapy
1. Initial call - keep it short
2. First interview - build alliance and hypothesize
3. Early phase of treatment - refining hypothesis and beginning to work on problems
4. Middle phase of treatment - family begins to take more active role
5. Termination - review and consolidate
N. Family assessment
1. Presenting problem
2. Understanding referral route
3. Identifying systemic context (interpersonal context of presenting concern)
4. Stages of life cycle
5. Family structure
6. Communication
7. Drug and alcohol abuse
8. Domestic violence and sexual abuse
9. Extramarital involvement (not just sexual affairs)
10. Gender (roles, expectations, and society)
11. Cultural factors (including mainstream)
12. Ethical dimension (therapist and family’s ethics)
O. Working with managed care - it’s necessary, so cooperate
288

IV. The Fundamental Concepts Of Family Therapy - Outline by Anabella Pavon
A. Conceptual influences on the evolution of family therapy
1. Opening thoughts
a. Systems theory
i. Consensus among family therapists about systems theory - most influential in
development
ii. Consensus among family therapists about systems theory - don’t really know
how to explain it
iii. Systems theory - abstract concept; way of thinking rather than established
doctrine
b. Many influences on family therapy
i. Biology v. Community mental health
ii. Physiology vi. Anthropology
iii. Cybernetics vii. Social work
iv. Psychosomatic medicine
2. Functionalism
a. Reaction to evolutionary method of removing from context
b. Anthropology - Malinowski and Brown - need to study in context
c. Functionalist premise - "...the adaptive value of any activity can be found if the
behavior is viewed in the context of the environment" (pg. 110)
d. Evolutionary theory and psychoanalysis
e. Bateson
f. Functionalist influence on family therapy
i. Deviant behaviors may be functional - (scapegoats)
ii. Brass tacks - families are organisms adapting to environment in context -
problems with family show problems with adjustment to environment
iii. Problem - "us against them"
3. General systems theory - Bertalanffy - a misinterpretation
a. All systems are subsystems
b. What did family therapy forget? Larger systems
c. Is it important for family therapists to consider values?
4. Cybernetics of families
a. Weiner’s idea of self - correcting systems
b. Feedback loop
i. Negative feedback loop - reduces deviation or change
ii. Positive feedback loop - amplifies deviation or change
c. Cybernetics applications to families: family rules, neg. Feedback, sequences of
interactions, positive feedback loops when neg. Feedback loops don’t work
d. Meta communicating - communicating about communicating
e. Bateson - introduced concept to family therapy - movement from linear circular
causality
f. Split - Haley control and power vs. Bateson
289

5. From cybernetics to structure
a. Haley - coalitions
b. Structural concept of families - subsystems with boundaries
c. Basic premise - chance structural context, change individual
d. Minuchin - cartographer of family structure
6. Satir’s humanizing effect - look at nurturance instead of control
7. Bowen and differentiation of self
a. Undifferentiated family ego mass
b. Differentiation of self
c. Multigenerational transmission process
8. Family life cycle
B. Enduring concepts and methods
1. Interconnectedness
2. Sequences of interaction
a. Triangles
b. Circular sequences
c. Indirect communication
3. Family structure
4. Function of the symptom
5. Circumventing resistance
6. The non pathological view of people
7. Family of origin
8. Focussing on solutions
9. Changing a family’s narrative
10. The influence of culture
290

V. Bowen Family Systems Therapy - Outline by Jared Warren
A. Sketches of leading figures
1. Murray Bowen
2. Philip Guerin
3. Thomas Fogarty
4. Betty Carter
5. Monica McGoldrick
6 Edwin Friedman
7. Michael Kerr
8. James Framo
B. Theoretical formulations
1. Differentiation of self
2. Triangles
3. Nuclear family emotional process
4. Family projection process
5. Multigenerational transmission process
6. Sibling position
7. Emotional cut-off
8. Societal emotional process
C. Normal family development
1. All families lie on continuum from emotional fusion to differentiation
2. Optimal family development: good differentiation, low anxiety, parents in good emotional
contact with families of origin
3. Fogarty elaborates 12 characteristics of well - adjusted families in "systems concepts and the
dimensions of self’ (1976)
4. Hallmark of well adjusted person is rational objectivity and individuality
5. Carter and mcgoldrick elaborated the family life cycle
a. Leaving home
b. Joining of families through marriage
c. Families with young children
d. Adolescence
e. Launching children and moving on
f. Families in later life
6. First - order change vs. Second - order change
291

D. Development of behaviour disorders
1. Symptoms develop when level of anxiety exceeds system’s ability to cope
2. Most vulnerable individual is most likely to develop symptoms
3. Bowen’s primary approach: calm down the parents and coach them to deal more effectively
with the problem
4. Guerin and fogarty put more emphasis on relationship with symptomatic child and nuclear
family triangles
5. According to bowen, behavior disorders result from emotional fusion transmitted from one
generation to the next
E. Goals of therapy
1. Keys to therapy: process and structure
2. Primary goals: decrease anxiety and increase differentiation of self
3. Creation of new triangle in therapy between husband, wife, and emotionally neutral therapist
4. Goals for extended family: developing one - to - one relationships and avoiding triangles
5. Approaches of Guerin and McGoldrick
F. Conditions for behavior change
1. Therapists must avoid taking sides and promoting triangulation, and avoid being reactive to
inevitable emotionality in families
2. Change requires awareness of entire family
3. Development of personal relationship with everyone in family
G. Techniques
1. Bowenian therapy with couples
a. Use of displacement
b. Therapist concentrates on process of couple’s interactions
c. Use of the "i - position"
d. Didactic teaching
2. Bowenian therapy with one person
a. Goal of differentiation
b. Genograms
c. Identifying triangles, reentry into family of origin
H. Evaluating therapy theory and results
1. Major shortcoming: can neglect importance of working directly with nuclear family
2. Evaluation has relied more on clinical reports than empirical data
I. Summary - Seven prominent techniques
1. Genogram
2. The therapy triangle
3. Relationship experiments
4. Coaching
5. The "I-position"
6. Multiple family therapy
7. Displacement stories
292

VI. Experiential Family Therapy Outline by Sarah Sifers
A. Leading figures and background
1. Emerged in the 1960s from humanistic psychology and drew heavily from gestalt therapy
and encounter groups (it is not very popular today)
2. Carl Whitaker
3. Virginia Satir (yes, the same one from communications family therapy)
4. Walter Kempler
5. Bunny and Fred Duhl
6. David Kantor
7. Current figures: Leslie Greenberg and Susan Johnson
B. Theoretical formulations
1. Commitment to freedom, individuality, personal awareness, individuals’ goals and values,
self - expression, and personal fulfilment, but largely a-theoretical
2. There is a wide variety of perspectives that a rather loosely connected under the heading of
experiential family therapy
C. Normal family development
a. Continuous growth and change and flexibility
b. Nurtures and supports individual growth and experience (which leads to increased growth in
the family) open (say anything) and constructive problem solving
c. Natural and spontaneous; freedom, privacy, and togetherness
D. Development of behavior disorders
1. Family and societal pressures prevent naturally occurring self - actualization
2. Denial of impulses and suppression of feelings (emotional deadness)
3. Seeking security and stability (rigid) rather than satisfaction
4. Loyalty to family stressed over loyalty to self
5. Mystification - smothering emotion and desire
6. Marriages consist of two people trying to work out conflicts that arise from each trying to
reconstruct his or her family of origin and their differences frighten them causing them to cling
closer together
7. Includes "normal" difficulties such as infidelity or "quiet desperation" and "invisible"
(culturally accepted) symptoms such as overwork and smoking
8. Intra-psychic defences that lead to interpersonal problems
9. Getting stuck during a life transition or change
10. Lack of warmth >>> avoidance >>> preoccupation with outside activities
11. "wrong" communication: blaming, placating, being irrelevant, and being super reasonable
293

E. Goals of therapy
1. Find fulfilling roles for self that don’t override concern for the needs of the family as a whole
(personal growth and family integration)
2. Increased self - awareness and expression that facilitates open family communication (you
can’t communicate what you’re not aware of)
3. Growth, personal integrity, freedom of choice, less dependence, "expanded experience,"
increased sense of competence, self - esteem, and well - being
4. Openly acknowledge support, and make use of individual differences
5. Being spontaneous, "crazy"
F. Conditions for behavior change
1. Evocative measures (resulting in anger, anxiety, etc.) To create therapeutic change by
opening people up or discover hidden emotions
2. Therapist must be warm and supportive, become a family member, be a "real person"
3. Therapist teaches by example how to be open, honest, and spontaneous
4. Including as many family members as possible (3 generations and kids)
5. Therapist needs to be mature, experienced, and have a satisfying family life
G. techniques
H. Evaluation
1. Clarifying communication (often through directives)
2. Focus on solutions rather than past grievances and point out positives
3. Support all family members’ self - esteem
4. Asking questions about emotions that are not expressed clearly (ind. Nonverbal cues)
5. Use of touch
6. Use of co - therapists to manage counter - transference
7. Very little formal assessment or history taking
8. Specific techniques: family sculpture, family puppet interviews, family art therapy, conjoint
family drawings, gestalt therapy techniques, symbolic drawing of family life space, role
playing, there - and then techniques, "psychotherapy of the absurd"
9. Interrupting family dialogues to work with individuals
1. No empirical studies, but some anecdotal support
2. Family therapists would benefit from being more honest and open with clients
3. Shifting the focus to an individual is a way to stop family bickering
294

VII. Psychoanalytic Family Therapy Outline by Anabella Pavon
A. Introduction
1. Many early family therapists have their roots in psychoanalytic training
2. Several psychodynamic therapists completely turned away from looking at the individual
3. 80s - family therapists looked at the individual again
4. Paradox: psychoanalysis is for the individual, family therapy the family. How can there be
Psychoanalytic family therapy?
B. Sketches of leading figures
1. Four groups of contributors to psychoanalytic family therapy - forerunners,
psychoanalytically trained pioneers, psychoanalytic ideas and thoughts when the field turned
from psychoanalytic ideas, and contemporary psychoanalytic family therapists
2. Adelaide Johnson - superego lacunae - gaps in personal morality passes on by parents
3. Erik Erikson - sociology and ego psychology
4. Wait ... There’s more - Erich Fromm predecessor of Bowen, Sullivan, Wynne, Lidz,
Acherman - strongest tie to psychoanalytic theory
5. Nathan Acherman - the psychodynamics of family life (1958) - first book dealing strictly
with diagnosis and treatment of families
6. Ivan Boszormenyi - Nagy - center of family therapy at the eastern Pennsylvania Psychiatric
Institute.
7. Dicks - worked with couples in England
8. John Bowlby
C. Theoretical formulations
1. "Practical essence of psychoanalytic theory is being able to recognized and interpret
Unconscious impulses and defenses against them ....
2. Freudian drive psychology - sexual and aggression
3. Self psychology - people want to be appreciated
4. Object relations theory - bridge between psychoanalysis and family therapy - relate to people
in the present partially based on expectations we develop in early relationships
D. Normal family development
1. Healthy psychological development based on good early environment - parents - good object
relations
2. Lots of talk about the mother and early mother/child attachment
3. Separation/individuation - provision of reliable support from mother is necessary
4. Parents need to be empathetic and model idealization
5. Ivan Boszormenyi - Nagy - contextual therapy - concerned with the ethics of families "loyalty and
trust provide the glue that holds families together"
295

E. Development of behavior disorders
1. Where non - psychoanalytic family therapist look at problems in interactions between people while
psychoanalytic therapists look at problems in the actual people in the
family
2. Symptoms come from attempting to cope with unconscious conflicts and the Anxiety that signals the
emergence of repressed impulses"
3. Some problems can occur with parents not accepting children’s separation
4. Kohut - mirroring and idealization - when these needs aren’t met from parents, go on to be showy and
seek admiration
5. Fixation and regression in families - after marriage, people can go back to behaviors seen when they
were younger
6. Nnagy - symptoms occur when trust breaks down in relationships - individuals feel the effects
7. Kernberg - blurred boundaries occur when connections are formed with family members
F. Goals of therapy
1. " . . . Free family members of unconscious restrictions so that they’ll be able to interact with one
another as whole, healthy persons on the basis of current realities rather than Unconscious images of the
past."
2. Therapy focuses on supporting defenses and helping communication instead of analysis of defenses
and finding repressed needs and impulses
G. Conditions for behavior change
1. Insight is necessary - in family therapy expand that insight knowing that psychological life goes
beyond conscious experiences. Want family members to understand and accept repressed parts of
personalities. Need to work through those things.
2. Important for the therapist to establish a sense of security
H. Techniques
1. Four basic techniques - listening, empathy, interpretation, and keep analytic neutrality
2. Don’t focus on reassuring or advise or confronting, silence is important. If they do intervene it’s to
provide empathic understanding to help member of the family open up. Analysts also clarify things that
appear to be hidden or need clarification
3. Mostly used with couples.
4. Therapists focus on the feelings associated with problems, not the causality to begin questioning
about what’s at the root of the problem
5. Explore in four areas with couples: internal experience, history of the experience, how partner can
trigger the experience, and how the context of session and therapist’s input might contribute to the
situation
6. "Family dynamics are more than the additive sum of individual dynamics" (p. 228)
7. Therapist has to have a hypothesis
296

VIII. Structure Family Therapy — Outline by Patty Salehpur
A. Assumptions
1. Family are individuals who effect each other in powerful but unpredicatable ways
2. The consistent repetitive organized and predictable patterns of family behavior are important
3. The emotional boundaries and coalitions are important
B. Salvador Minuchin
1. Always concerned with social issues
2. Developed a theory of family structure and guidelines to organize therapeutic techniques
3. 1970 headed Philadelphia Child Guidance Clinic where family therapists have been trained in
structural family therapy ever since
4. Born in Argentina , served in the Israel army as a physician, in the USA trained in child
psychiatry and psychoanalysis with Nathan Ackerman, worked in Israel with displaced children,
also worked in the USA with Don Jackson with middle class families.
5. Fist generation of family structural therapists: Braulio Montalvo, Jay Haley, Bernie Rosman,
Harry Aponte, Carter Umbarger, Marianne Fishman, Cloe Madanes, and Stephen Greenstein.
C. Theoretical formulations - three essential constructs
1. Structure — the organized pattern in which family members interact, predictable sequences
of family interaction, patterns of interaction. Structure involves a series of covert rules. There
are universal and idiosyncratic constraints. Families may not be able to tell you the family
structure, but they will show it to you in their interactions.
2. Subsystems — Families are differentiated into subsystems of members who join together to
perform various functions. Each person is a member of one or more subsystems in the family.
Some groupings are obvious and based on such factors as generation, gender, age or common
interests. Other coalitions may be subtle. Every member may play many roles in various
subgroups.
3. Boundaries are invisible barriers that regulate the amount and nature of contact with
members. They range from rigid to diffuse, clear to unclear, disengaged to enmeshed
D. Normal family development
1. Marriage begins with accommodation and boundary making
2. Couples are influenced by the structure of their families of origin
3. Couples also form boundaries with their families of origin
4. The advent of children requires that the structure of the family change
E. The development of behavior disorders
1. Family dysfunction results from stress and failure to realign the structure to cope with it.
2. Disengaged families have rigid boundaries and excessive emotional distance. They fail to
mobilize to deal with the stress.
3. Enmeshed families have diffuse boundaries and family members overreact emotionally and
become intrusively involved with one another. These actions hinder mature actions to resolve
stress.
4. Subsystems in the family may be disengaged or enmeshed.
5. Power hierarchies may develop which may be weak and ineffective or rigid and arbitrary.
6. Conflict avoidance prevents effective problem solving.
7. Generational coalitions may also prevent effective problem solving.
8. Family structure may fail to adjust to family developmental processes.
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9. A major change in family composition demands structural adaptation.
10. Symptoms in one family member may reflect dysfunctional structural relationships or
simply individual problems.
F. Goals of therapy
1. Changing family structure - altering boundaries and realigning subsystems
2. Symptomatic change - growth of the individual while preserving the mutual support of the
family
3. Short-range goals may be developed to alleviate symptoms especially in life threatening
disorders such as anorexia nervosa, but for long-lasting effective functioning the structure must
change. Behavioral techniques fit into these short-term strategies.
G. Techniques — join, map, transform structure
1. Joining and accommodating, then taking a position of leadership
a. Listen to "I" statements
2. Enactment for understanding and change
3. Working with interaction and mapping the underlying structure
a. Looking at the power hierarchies
b. Using enactment to understand and clarify
c. Looking at the boundary structures
4. Diagnosing
a. individual vs. subgroup
b. structural diagnosis
5. Highlighting and modifying interpersonal interactions is essential
a. Control intensity by the regulation of affect, repetition and duration
b. Don’t dilute the intensity through overqualifying, apologizing or rambling
c. Shape competence, e.g. "It’s too noisy in here. Would you quiet the kids."
6. Boundary making and boundary strengthening
a. Seating
b. Seeing subgroups or individuals to foster boundaries and indivduation
c. Clarify circular causation
7. Unbalancing may be necessary
a. Taking sides
b. Challenging
c. Directives
8. Challenging the family’s assumptions may be necessary
a. Teaching may be necessary
b. Pragmatic fictions
c. Paradoxes
d. Therapist sometimes must challenge the way family members perceive
reality, changing the way family member relate to each other offers alternative
views of reality.
9. Therapists must create techniques to fit each unique family
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