Dr. krishnan's family therapy

Introduction to Family Therapy

Dr. S. KrishnanAssociate Professor of PsychiatryGovernment Medical College, Thiruvananthapuram

Before you start…

You are an outsider You don’t have a right to intrude and peep You are not a savior or judge Don’t promise to solve all the family

issues Beware of transference issues Family is different from HOME

Family Therapy

An intervention which focuses on altering the interactions among family members and improve the functioning of the family as a unit of individual members of the family

Birth of Family Therapy

Numerous phenomena gave rise to family therapy and the systems perspective in the 1940s & 1950s Small group dynamics Marriage Counseling Research on schizophrenia The Child Guidance Movement

Indications

Precipitating

Perpetuating

Maintaining

Therapist’s Task

Identify family’s unspoken rules

Disagreements about who makes these rules

Distorted ways of communications in the family

Rigid intergenerational patterns which cause distress within or between individuals

Of use in…

Child psychiatric problems Adolescent crises Schizophrenia Bipolar disorders Dissociative disorders Somatoform disorders Dysthymia Recurrent depressive disorders And many more…

Role of therapist

Understand the rules

Modify the rules

Improve communicat

ion

How many sessions

5-10 sessions (Milan Approach) at intervals of 1 month or more

2-3 sessions when the patient is in the hospital (preferably no more than one session per week)

Each session of 1-3 hours duration Duration of therapy depends on the model

used: Problem solving models (short duration) Growth oriented models ) (long durations -

years)

How many Family Members?

How many Therapists?

1

2

35

10

Goals…

Improved communication

Improved autonomy for each member

Improved agreement about roles

Reduced conflict

Reduced distress in the index client

Family Cycle

Families in Distress…

All families face two types of stressors

Developmental stressors

Environmental stressors

Families in distress are not sick, but have been unable to adjust to the stressors

Developmental Stressors

Marriage 1st child in family 1st teenager in

family Gender role

changes Death of a parent Children leave

home

Environmental Stressors

Fire Injury War New job or job

loss Financial

stressor Rape

A Distressed Family

Is often unwilling to take responsibility Interprets problems from a linear

causality perspective, rather than a circular perspective.

Suffers a confusion of levels (children and parents)

Forms coalitions (a parent and a child against another parent)

Appoints children to quasi-adult roles (a child taking on the role of one parent’s confidant)

Why families enter therapy?

Stressors -- environmental and developmental -- arise in the normal course of a family’s life.

The failure of its members to cope with and accommodate to stressors leads members to disengage from some members, and become enmeshed with others

Indirectness of communication and anxiety ensues, with triangular relationships substituting for direct encounter and the pursuit of intimacy.

Identified client is usually reason for entering therapy, but often only the symptom of family distress..

Triangular Relationship

Concept by Murray Bowen Two-person relationship is the basic unit of

any emotional system. Under stress the two-person system tends to

draw in a third person to stabilize ( three-person system of two-against-one).

When anxiety builds up in any one triangle, it spills over into other triangles, filling the whole family system.

Problematic behavior patterns

Monica McGoldrick, Genograms. W.W.Norton, 2007

Triangular Relationship

Families repeat themselves. What happens in one generation will

often repeat itself in the next, though the actual behavior may take a variety of forms.

Monica McGoldrick, Genograms. W.W.Norton, 2007

Rules Matter

Families have rules that determine how balance is reinstated. If something violates the rules, then one of two things happen: Members reassert the

rules. The family changes the

rules.

Values Matter

Families have values that assign meaning to various events. It is important to understand those values in working with families.

Values are a function of family and cultural origins.

Language Matters

Families have ways of describing people and situations that reflect their values and rules.

It is important to understand the way the family uses language, in order to effectively reframe people and situations whenever a more positive viewpoint is possible.

Reframing is using language to describe a person or a situation in a more positive way.

Models of Family therapy

Psychodynamic-experiential models Bowen model – family systems

model Structural model

General systems model

Bowen Family Systems Theory:Basic Constructs

Murray Bowen The family is an emotional

system composed of many generations, whether living or dead.

The goal of therapy is the differentiation of self from one’s family-of-origin.

Individuals who are not differentiated form unstable relationships and are prone to triangulation.

Bowen Family Systems Theory:Therapeutic Techniques

The goal of therapy is differentiation. Focus on family and relationship

patterns rather than specific issues. Look for signs of emotional cut-off and

triangles. The stance of the therapist is that of observer.

Therapists must be highly differentiated to avoid the emotionality of the family system.

Genograms help clients map multigenerational processes.

Systems Approach to Family Therapy

Salvador Minuchin General systems approach to family

therapy Focused on the balance between

stability & change, openness & closedness.

Its efficacy has been demonstrated with a wide variety of family configurations.

First major influence on family systems theory…

Observations made of the communication styles in schizophrenic families.

Double bind Marital schism Marital skew Pseudomutual and

pseudohostile communication

Double Bind

A view that when an individual receives an important message with two different meanings and is unable to respond to it, the individual is in an impossible situation.

If such messages are repeated over time, individuals may begin to show signs of schizophrenia.

Marital Schism

A situation in which one parent tries to undermine the worth of another (parent) by competing for sympathy or support from the children.

Marital Skew

A situation in which the psychological disturbance of one parent dominates the family’s interactions.

An unreal situation for family members is created so that the family can deal with one member’s disturbance.

Pseudomutuality

Presenting an appearance of open relationships in a family so as to conceal distant or troubled relationships within the family.

Members develop roles that they play rather than relating honestly.

General Systems Theory

A system represents a set of units that stand in some consistent relationship to one another.

A system is organized around relationships.

Elements (units) interact with each other in a predictable, “organized” fashion.

Units, once combined form an entity - a whole, greater than the sum of its parts.

Therefore, no element can be understood in isolation.


The organization of relationships may include groups, alliances, coalitions, and tensions.

The organization gives clues to the system’s consistent or repetitive interactive patterns…know as rules.

Family Rules

Family rules: Family interactions follow certain

persistent patterns – rules (Jackson, 1965) Redundancy principle – a family interacts

in repetitive behavioral sequences. Rules may be▪ Descriptive - metaphors describing patterns of

interaction.▪ Prescriptive – directing what can or cannot

occur between members.


How changes in one family member can bring about changes in another, by looking at the entire family as a unit.


Feedback: the reinsertion into a system of the results of its past performance, as a method of controlling the system.

Negative feedback: Information that flows back to a system to reduce behavior that causes disequilibrium.

Positive feedback: Information that leads to deviation from the system’s norm, bringing about change and a loss of stability.


Equifinality: the ability of a system to arrive at the same destination from different paths.

Homeostasis: A dynamic state of balance or equilibrium in a system, or a tendency toward achieving and maintaining such a state in an effort to ensure a stable environment.

A step-by-step approach

to Family Therapy…

Prerequisite

Assessment of the family structure Summarizing family structure –

GENOGRAM (Murray Bowen) Current and past state of family life Roles of the members Therapist tries to answer two

questions: How the family functions Whether family factors are involved in

client’s problems

Initial Phase

1) Inviting entire family to session 2) Joining and building a collaborative

relationship 3) Assessing problem from multiple

perspectives 4) Assessing family rules, values, language

patterns, and goals (teleological lens) 5) Assessing cultural issues (multicultural

lens), and family of origin for patterns across the generations (developmental lens) genogram

Interventions

6) Observing, or tracking interactional patterns -- asking process questions (Bowen) educates the family about circular causality I-position encourages taking responsibility

and ending of blame 7) Observing and encouraging typical dynamics

-- enactments (Minuchin). Therapist may use Reframing, poking, “stroke and a kick” Assigning tasks▪ boundary adjustments▪ eliciting and supporting competencies

Circular Questioning

One person is asked to comment on the relationships of others.

Others are asked to comment on her response

Purpose is to discover and clarify confusing and conflicting views

Paradoxical injunctions

Designed to provoke the family into making changes which they cannot make in other ways

Paradoxical injunctions are impossible or counter intuitive suggestions which force the family to confront their hidden or unacceptable motives

How does the family function?

Structure (genogram) (single parent, step parent, size and age of spread of he sibship)

Relationships (close, distant, uncooperative, conflictual)

Patterns of interactions (child siding with one parent against the other)

Changes and events (births, deaths, departures, financial problems

Genogram

Are family factors involved in client’s problems?

Contribute to patient’s problems (son does not want to leave widowed mother after marriage)

Supporting the client (codependence)

Reacting to the client’s problems (unrelated other problems may be there)

Cognitive Distortions

Denial Distortions Arbitrary inferences Selective abstraction Overgeneralization Minimization Maximization Dichotomous thinking Personalization…

Restructuring Concepts

Supporting parents (hierarchies) Insulating parents from their own families

of origins Insulating parents from children Establishing direct communication or “De-

triangulating” Nurturing competencies through reframing

symptoms as strengths and assigning tasks

Redefining relationships one-to-one with family of origin

Typical Problems

Critical/Enmeshed Parent / In-Law

Acting out Teenager

Affairs

Critical/Enmeshed Parent / In-Law

Unwillingness of adult child to assert boundaries

Unwillingness of son/daughter in-law to confront parent directly

Can lead to carryover of anger of adult child to spouseEstablish better boundaries and privacy between couple and parentConfront in-law by adult childEstablish direct relationship between son/daughter in-law and parent in-law (de-triangulation)

Acting out Teenager

Usually one parent is disengaged from the family

The other parent is usually over-involved in the “problem” child’s life.

There is a lack of intimacy between couple due to preoccupation with child.

There is often a neglect of other children’s needs

Acting out Teenager

Get couple to work together to resolve differences, clarify rules, and express expectations

Reframe teenager’s behavior if possible

Encourage direct communication between teenager and disengaged parent(s) without interference

Affairs

Usually occurs during major developmental or environmental stressors, which disrupt communication and intimacy between spouses

Can be due to lifelong suppression of one’s needs in the context of a marital relationship

Can be due to lack of intimacy due to family pressures

Affairs

Establish that it takes two for an affair to happen.

Need to communicate unspoken needs perhaps too much difference or

“complementarity” perhaps not enough “similarity,” and

quality time explore unexpressed dreams

Tools for all seasons

Focus on process (how) rather than content (what)

Focus on interpersonal dynamics, rather than personal feelings and thoughts

Focus on here and now, vs. there and then

Tools for All Seasons

Teach Circular Causality/Reciprocity Ask “process questions” that encourage

linking one’s own behavior to the effects on others, example: “What effect does it have on her when you withdraw and watch TV?” or “Have you tried to talk with him about it rather than giving him the silent treatment?”

Encouraging I-position, not talking about others

Explore cross-generational patterns

Tools for All Seasons

De-triangulating▪ Getting people to talk directly without interruptions▪ Role playing direct communication▪ Having everyone present for meeting

Acknowledging competencies and putting them to work

Reframing -- “Stroke and Kick” -- Reframe and redirect

Genograms for cross-generational patterns

Analyse Transactions

Criteria for Treatment Termination When FMs can complete transactions When FMs can interpret hostility When FMs can see how others see them When FMs can see how they see themselves When one member can tell others what is

hoped, feared and expected from them or how they manifest themselves

When FMs can disagree When FMs can make choices When FMs can learn through practice When FMs can free themselves from harmful

effects of past models When FMs can give clear message

Modifications of Techniques

Family group therapy

Social network therapy

Paradoxical therapy

Thanks a Lot

Dr. krishnan's family therapy

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