Module 12. Therapeutic Approaches in Social Case Work Interventions: Family Therapy

Transcription

1 Module 12 Therapeutic Approaches in Social Case Work Interventions: Family Therapy Component 1A Role Name Affiliation Principal Investigator Dr. Geeta Balakrishnan College of Social Work, Nirmala Niketan, Mumbai Paper Coordinator Prof. Xavier Kanickairaj National Institute of Social Work and Social Sciences, Bhubaneswar Content Writer Prof. Kirubakaran Loyola College, Chennai Content Reviewer Dr. Yamini Suvarna College of Social Work, Nirmala Niketan, Mumbai Language Editor Ms. Marianne Claudia Rayer Research scholar, Pondicherry University, Pondicherry Component 1B Subject Name Paper Name Description of Module Social Work Education Working with Individuals and Families Module Name Module ID Pre Requisites Objectives Therapeutic Approaches in Social Case Work Interventions: Family Therapy SW/SCW/12 An understanding of the principles and methods of working with individuals and families -to know the historical framework of family therapy -to understand the prominent schools of family therapy - to gain an insight into the various techniques of family therapy Key words Multiple-Family Group Therapy, eclectic, Communication Theory, Systems Theory, Reality Therapy, Multigenerational Family Therapy, Triangulation, Genogram, Satir Techniques, Family Reconstruction

2 Quadrant 1 1. Introduction Family therapy, also referred to as couple 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 emphasises family relationships as an important factor in psychological health. The different schools of family therapy have in common 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 catalyses the strengths, wisdom, and support of the wider system. In early years of the development of the field, 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 organisational dynamics. 2. Objectives This module deals with the family therapy. After going through this module, students will become familiar with the following: 1. The historical framework of family therapy, 2. The prominent schools of family therapy and 3. The various techniques of family therapy. 3. Nature and Definition of Family Therapy Family therapy refers to the joint treatment of two or more members of the same family in order to change unhealthy patterns of communication and interaction. Family therapy is generally initiated because of psychological or emotional problems experienced by a single family member, often a child or an adolescent. These problems are treated as symptomatic of dysfunction within the family system as a whole.

3 The social case worker as a therapist focuses on the interaction between family members, analysing the role played by each member in maintaining the system. Family therapy can be especially helpful in dealing with problems that develop in response to a particular event or situation, such as divorce or remarriage, or the birth of a new sibling. It can also be an effective means to draw individuals who feel threatened by individual therapy into a therapeutic setting. The case worker can understand the individuals better by assessing the interactions within the entire family. A dysfunction within a family is expressed as a symptom. In every family, there will be a person who is the real client while someone else is branded as the identified patient. Actually the identified client bears the symptom of the dysfunction of the family. The dysfunctional patterns may be transmitted through many generations. Therefore the identified client s problem might be a symptom of how the system functions, not just a symptom of the individual s maladjustment, history, and psychosocial development. The family systems perspective assumes that a client s problematic behaviour: 1) May serve a particular purpose of the family, 2) May be an indication of the inability of the family to operate productively, especially during the developmental transitions, or 3) May be a symptom of dysfunctional patterns handed down across generations. Since a client is operating in a living system, any change in one part of the unit has repercussions in other parts and so any treatment should address the entire system. The family systems approach does not ignore the fact that an individual may have disorders independently of the family but the consideration in the family systems approach is that even though an individual may have disorders of his/her own, the other family members have to react to the disorder and make systemic adjustments to the problem. Thus the problem of the individual becomes a systemic problem. The goal of the family systems therapy is a change in the system, which in turn will produce a change in the individual members. The members are made to change their dysfunctional patterns of relationship to functional ways of interacting. 4. History and Theoretical Frameworks of Family Therapy 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 nonkin members of the community. These interventions were often conducted by particular members of a community for example, a chief, a priest, a physician and so on usually as an ancillary function. Family therapy as a distinct professional practice had its origins in the social work movements of the 19th century in England and in 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 counseling. The formal development of family therapy dates to the 1940s and early 1950s with the founding of the American Association of Marriage Counselors in1942 and through the work of various independent clinicians and groups in England (John Bowlby), 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

4 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. 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. The members of the Bateson Project 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 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 the society s problems. 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 emphasised 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 either directly in therapy sessions, or via homework, journeys home. 4.1 Psychodynamic Family Therapy This more than any other school of family therapy; deals directly with individual psychology and the unconscious in the context of current relationships. It 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. 4.2 Multiple-Family Group Therapy This precursor of psychoeducational family intervention, emerged, in 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 by Ross Speck and Carolyn Attneave, and the emergence of behavioural marital therapy (renamed behavioural couples therapy in the

5 1990s) 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. However, 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. 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 multisystemic therapy (MST). Multicultural, intercultural, and integrative approaches are also being developed. Many practitioners claim to be eclectic, using techniques from several areas, depending on 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 approaches. 5. Techniques of Family Therapy Family therapy uses a range of counseling 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 range is between five and twenty sessions. The case worker playing the role of 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 analysing 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 elucidate the patterns of relationships across generations.

6 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 case worker-family therapist may focus on analysing 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. 6. 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 self-determination, connectedness and independence, functioning versus authenticity, and questions about the degree of the therapist s pro-marriage/family versus pro-individual commitment. 7. Models of Family Therapy There is no single unified theory of family systems therapy. Hence we find some major models of family therapy. Some of the outstanding approaches are: 1) Multigenerational family systems model - Murray Bowen, 2) Human Validation process model - Virginia Satir, 3) Experiential/symbolic approach - Carl Whitaker, 4) Structural approach Salvador Minuchin, 5) Strategic approach Jay Haley & Cloe Madanes, and 6) Recent innovations such as Constructionism. We shall review the prominent models of family therapy in the following sub-sections. 7.1 Multigenerational Family Therapy Murray Bowen s family systems theory is also understood as the transgenerational or intergenerational family therapy. Since a predictable pattern of interpersonal relationships connects the functioning of the family members across generations, a family can be understood well when we analyze it from at least three-generation perspective. Central to his theory, he identified eight key concepts: differentiation of the self, triangulation, the nuclear-family emotional system, the family-projection process, the

7 multigenerational transmission process, sibling position, emotional cutoff and societal regression. Among them he focused more on differentiation of the self and triangulation Key Concepts in Multigenerational Family Therapy Differentiation of the Self Differentiation of the self means both the psychological separation of intellect and emotion as well as independence of the self from others. That is, differentiation can be at the intrapsychic and interpersonal levels. Intrapsychic differentiation is the ability to separate feeling from thinking. In an undifferentiated person his/her intellect is so flooded with feelings that he/she is almost incapable of objective thinking. A differentiated person can choose between being guided by his/her feelings or by his/her thoughts. It is a matter of choice. Interpersonally an undifferentiated person has difficulty in separating himself/herself from others and tends to fuse himself/herself with dominant emotional patterns in the family. Usually lack of differentiation between thinking and feeling occurs along with lack of differentiation between oneself and others. A healthy position for an individual is that one is fused with the family and also remains separate as an individual Triangulation In any intimate relationship between two individuals there is bound to be anxiety. When there is stress in their relationship, they may invite a third party into the relationship to reduce their anxiety and gain stability. This in essence is triangulation. It is hoped that the problem between the two individuals is solved but it is not the case. The emotional tension may seem lessened but the underlying conflict is not resolved or rather it is made worse by the process of triangulation. Triangulations usually happen in the family when parents have conflicts; to reduce their anxiety and emotional tension they involve their son or daughter into the game. Triangulation resembles the psychological games of Dr. Eric Berne. In a game of persecutor and victim, a third party, a rescuer enters in. They keep changing roles and play the game. In triangulation too, two parties experiencing distress somehow manipulate a third party to get involved in the distress so that their distress is diminished. Anyway triangulation is a psychological game pattern and it is an unhealthy way of coping with distress and problematic situations. On the surface, triangulation may apparently be innocent and healthy but it is not so. For example, a woman experiencing distance from her husband may involve herself too much in caring for her son or daughter. This caring for the child is only a way of reducing the tension she is experiencing on account of the distance from her husband Nuclear Family Emotional Process Emotional forces usually operate over the years in recurrent patterns. If there is a lack of differentiation in the family of origin, that will lead to emotional cutoff from parents which in turn will lead to fusion in marriage. The less the differentiation prior to marriage, the more will be the fusion with the spouse. But this new fusion may not be stable and so may produce one or more of the following problems: 1) reactive emotional distance between the spouses, 2) physical or emotional dysfunction in one spouse, 3) overt marital conflict, and 4) projection of the problem onto one or more children. The intensity of the above mentioned problems will be depending upon the degree of undifferentiation, the extent of emotional cutoff from families of origin, and the level of stress in the system Family Projection Process

8 Family projection process is the transmission of their immaturity and lack of differentiation by the parents to the children. For example when the husband distances himself from his wife, the wife tends to care for a child extraordinarily which is not a caring concern but an anxious and enmeshed concern. The child that is the object of this projection process becomes attached to the parents either positively or negatively and the child will be the person least differentiated. The emotional fusion between the child and the mother may be a warm, dependent bond or an angry, conflictual struggle. Here the mother s anxiety is focused on the child and the child s functioning is stunted. Because of the stunted development of the child, the mother all the more over-controls the child and thus gets relief from her own anxiety but at the same time cripples the child emotionally Multigenerational Transmission Process It is a process by which the family s emotional process is transmitted through multiple generations. The one who was involved in the emotional fusion with the family of origin moves towards a lower level of differentiation of self, while the one who was least involved moves towards a higher level of differentiation. Emotional illnesses are transmitted beyond the individual and nuclear family to several generations. Thus an identified patient of the family is the result of the emotional problems of his/her parents, parents parents and so on for several generations. The problem is the result of a multigenerational sequence in which all family members are actors and reactors Sibling Position Children tend to develop certain fixed personality characteristics depending on the sibling position in the family. Bowen s perspective offers a new outlook to the traditional concept of sibling rivalry by recognizing the triangular complications of the siblings relationship with their parents. Sibling rivalry is only one aspect of the triangular process. It is intimately connected with the involvement of parents. Thus a triangular relationship is responsible for the type of characteristics children develop Emotional Cutoff It is simply the way we manage undifferentiation and emotional intensity associated with it between generations. If the emotional fusion between generations is more, the greater will be the likelihood of cutoff. Some do it by literally moving away from the parents and settling down in a far-off place and some others move away from the parents emotionally Societal Emotional Process According to societal emotional process, the emotional process in society influences the emotional process in families. The societal emotional processes are like a background influence affecting all families. For example, in a society where there is a great social pressure, the crime rate in the same society will be high. 7.2 Bowenian Family Therapy The goal of Bowenian family therapy is to reduce the anxiety and find symptom relief and secondly to increase the level of differentiation of the self in each member of the family. The way to change oneself is by changing the relationship with others in the family of origin.

9 The following paragraphs discuss the techniques used in Bowenian Family Therapy Genogram One of the techniques used by Bowen is genogram work or family diagram. It is assumed that whatever occurs in one generation is likely to extend to the following generations and so Bowen thought of collecting and organizing important information over at least three generations. It was done in the form of a diagram, which he called genogram. A genogram is a pictorial layout of each partner s threegenerational extended family. From this one can have an understanding of the critical turning points of the emotional process in the family. Mostly births, deaths, marriages and divorces and even habits like drinking are marked in the genogram. It can also provide information of cultural and ethnic origins, religious affiliation, socioeconomic status, type of contact among family members, and proximity of family members. In a genogram the person with a problem is called index person (IP). The index person is indicated on the genogram with either a double square (for males) or a double circle (for females). All other men are designated with a single square, and women with a single circle. In each square or circle, the name of the person is noted along with the year the person was born in. An X through a person s name and square or circle indicates death. Next to the person is indicated the year and the cause of death. Shading half of the square or circle indicates problem with alcohol. Solid lines ( ) between people indicate a formal and direct relationship. They indicate marriage and the year of marriage is noted above the line. A line made of dashes ( ) indicates a relationship that is not formalized but the individuals live together. A jagged (^^^^^^^) line between two persons indicates conflict. Three solid lines between individuals indicate a very close or even fused relationship. A double line indicates a close relationship only. A dotted line ( ) between individuals indicates a distant or even disengaged relationship Asking Questions The second Bowenian technique is called asking questions. Bowen designed questions that are meant to get the clients to reflect on the role they play in relating themselves with the members of the family. The questions are called circular or circularity since they focus on the change in relation to others who are recognized as having an effect on the person s functioning. Bowen s theory is criticized for its emphasis on separation of thought and feelings as well as therapeutic detachment, which elevate rationality and autonomy over connectedness, integration and interdependence. 7.3 Human Validation Process Model The model established by Virginia Satir is called conjoint family therapy. For her, techniques are secondary and what is primary is the relationship the therapist establishes with the family. She emphasizes the enhancement and validation of self-esteem, family rules, congruence versus defensive communication patterns, sculpting, nurturing triads, family mapping (genogram), and family life-fact chronologies Family Life As children we enter into preexisting systems, especially the family system. The family system of which we become a part already has rules, especially the rules that govern communication such as who says what, to whom and under what conditions. Worried parents set more rules to control their children. When rules are perceived as absolute and impossible to be followed, they pose a problem for the individuals. As children we abide by the rules given by the family but as adults, rules may be ineffective and dysfunctional. In a healthy family, there will be a few rules and they are consistently applied.

10 Functional Versus Dysfunctional Communication in Families There are evident differences between functional and dysfunctional communication patterns. In a family where there are functional communication patterns the members are allowed to have their own individual lives and also a shared life. Change is always welcome and taken as an opportunity for growth. There is a lot of flexibility and open communication. In a family where there are dysfunctional communication patterns, one notices the opposite qualities of those mentioned in the functional communication patterns. There is hardly any support for individuality and relationship is mostly strained and there is no autonomy for the members nor is there any genuine intimacy. Since rules cannot keep the system together, eventually the system breaks down Defensive Stances in Coping with Stress When The Family System Is Crumbling Due To Escalating Stress, The members tend to resort to defensive stances. Four universal communication patterns that serve as defensive postures or stress positions have been identified, namely, placating, blaming, being super reasonable and being irrelevant. 1) Placating Here people are driven by the please me driver. They sacrifice themselves to please others. Since they do not have an inner sense of values, they depend upon others and do what others expect of them. 2) Blaming The persons who take the stance of blaming will sacrifice others at the altar of their own selfish interest. Assuming a dominant role and commanding demeanour, they find fault with everyone else in an attempt to prove themselves to be right. This is a perfect game of blemish. The people who play the game of blemish find fault with others over insignificant matters in a bid not to be found fault with by others. They frequently play the game of if it were not for you and thus avoid taking responsibility for their own mistakes. Those who play this game perpetuate their abject condition by putting the blame on others and by not taking the initiative to improve their lot. 3) Super-Reasonable The people who take up the position of being super-reasonable strive for absolute control over themselves, others and the environment and are purely governed by principles, which ultimately isolate them and make them loners. 4) Irrelevant Behaviour Here people have a pattern of distractions in a bid to diminish their hurt, pain and stress. They are unable to relate to what is going on right now. They are in constant motion with everything going on in different directions at the same time. They are frightened of stress and so avoid taking a clear position lest they offend others Therapy Goals Clear communication, expanding of awareness, enhancing potentials for growth, especially in selfesteem, and coping with the demands and process of change are the main goals of therapy for Satir. She specially identifies three goals which are 1) each one in the family should be able to report honestly about what he or she sees, hears, feels, and thinks, 2) decisions in a family are to be made through exploring individual needs and negotiating rather than through power, and 3) differences need to be openly

11 acknowledged and used for growth Satir Techniques Some of the techniques Satir developed are family maps (similar to genograms), family life-fact chronology (a listing of a family s three-generation history), family sculpting, drama, reframing, humour, touch, parts parties, and family reconstruction. Techniques from Gestalt therapy, psychodrama, and person-centred therapy are also used Family Sculpting The therapist asks each member of the family to arrange the other members of the family in a meaningful tableau. This is a graphic means of portraying each individual s perceptions of the family, in terms of space, posture, and attitude. Family sculpting is used to increase the awareness of the members with regard to how they function and how others view them in the family system. It could be done either by the therapist or by any one of the members of the family. Especially when an identified patient does the family sculpting, it becomes vividly evident how dysfunctional the patterns are in the family system Family Reconstruction Family reconstruction is a form of psychodramatic reenactment through which the clients explore significant events in the lives of the previous three generations of their family. This method has the advantage of helping the family members identify the roots of their old learnings, formulate a more realistic picture of their parents, and discover their unique personality. The clients make use of the group members to simulate three generations of their family life and thus make sense out of past experiences Parts Parties Each person is seen as a system of parts, both positive and negative. A parts party is a psychodrama, often used in groups, to help the individual acknowledge and integrate multiple aspects of the self. It is a means to show members what is happening when they interact. 7.4 Experiential/ Symbolic Family Therapy Experiential family therapy is also known as the experiential/symbolic approach, which has strong connections with other existential, humanistic, and phenomenological orientations. This approach stresses choice, freedom, self-determination, growth, and actualization. Usually the family members and the therapist interact with one another and so the personal involvement of the therapist with the family is important and therefore there are no techniques proposed. This approach is pragmatic and so in some sense anti-theoretical. Its goals are to promote the feeling dimension, which are spontaneity, creativity, the ability to play, and the willingness to be crazy. For Whitaker what brings about change is experience and not education. Most of the human experience occurs on the unconscious level, which can be reached symbolically. Here symbolic will mean finding multiple meanings for the same process. Carl Whitaker 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. 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

12 importance of including extended family members, especially the expressive and playful spontaneity of children, in treatment Therapist s Role and Function The therapist creates a family turmoil and then coaches the members through the experience. His interest is mainly in his interaction with the family members. The therapist focuses on the process of what is unfolding during the session, on the impulses and symbols that emerge during the sessions. At times he is also outrageous in his approach so as to encourage family members to gradually accept their moment-bymoment experiencing Three Phases of the Therapy Family therapy occurs in three phases namely engagement, involvement, and disentanglement. Accordingly the role of the therapist too changes throughout the therapy. Initially the therapist assumes an all-powerful position thereby increasing the anxiety the family is experiencing. This makes the members recognize interactional patterns. At this point the family comes up with alternative ways of operating. The therapist might change his role from being a dominant and parental figure to being an adviser and a resource person. When the family members assume responsibility for their own living and changing, the therapist becomes more personal and less involved in the family system. Change in the family is to be experienced rather than designed. Change will take place only when the therapist disturbs or frustrates the family process. 8. Summary Family therapy has a variety of origins. It is related to the long-standing emphasis of psychoanalysis and other psychodynamic approaches on the central role that early family relationships play in the formation of personality and the manifestation of psychological disorders. Family therapy, either alone or in conjunction with other types of treatment, has been effective in the treatment of children suffering from a variety of problems, including anxiety, enuresis (bed-wetting), and eating disorders, and also in working with victims of child abuse. In addition to alleviating the child s initial complaint and improving communication within the family unit, family therapy can also help reduce stress and conflict by helping families improve their coping skills. There are a number of approaches to family therapy. Perhaps the best known is structural family therapy, founded by Salvador Minuchin. It is a short-term method that focuses on the present rather than the past. This school of therapy views a family s behaviour patterns and rituals as central to the problems of its individual members. Poor communication skills play a key role in perpetuating destructive interactions within families, such as the formation of alliances among some family members against others. The goals of structural family therapy include strengthening parental leadership, clarifying boundaries, enhancing coping skills, and freeing family members from their entrenched positions within the family structure. Minuchin divided families styles of interacting into two basic types enmeshed and disengaged, considering behaviour at either extreme as pathological, with most families falling somewhere on a continuum between the two. Minuchin believed that the functioning of family systems prevented individuals from becoming healthier emotionally, because the family system relied on its troubled member to play a particular role in order to function in its accustomed way. This stability is disrupted if an individual changes significantly. Psychodynamically oriented family therapy emphasises unconscious processes and unresolved conflicts in the parents families of origin. The lasting effects of traumatic experiences such as parental divorce and child abuse are explored. This type of therapy focuses more on family history

13 and less on symptoms, resulting in a lengthier therapeutic process. Therapists who employ an object relations approach emphasise the importance of having the parents in a family work out conflicts with their own parents. Some practitioners include grandparents in their work with families in order to better understand intergenerational dynamics and deeply rooted behaviour patterns. Ivan Boszormenyi-Nagy, a well-known proponent of this orientation, would only treat families when members of three generations could participate in therapy sessions. Behavioural family therapy views interactions within the family as a set of behaviours that are either rewarded or punished. The behavioural therapist educates family members to respond to each others behaviour with positive or negative reinforcement. A child might be discouraged from repeating a negative behaviour, for example, by losing some privileges or receiving a time-out. Positive behaviour might be rewarded with the use of an incentive chart on which points or stickers are accrued and eventually exchanged for a reward. Behavioural approaches sometimes involve the drawing up of behavioural contracts by family members, as well as the establishment of rules and reinforcement procedures. Several other family therapy approaches, including that of Virginia Satir, are primarily concerned with communication. Satir s system combines the teaching of family communication skills, the promotion of self-esteem and the removal of obstacles to the emotional growth so that family members can have full access to their innate resources.