FAMILY THERAPY

HISTORY OF FAMILY
THERAPY
Family therapy developed after the
Second World War, Among the first
to point out the importance of
family therapy were Christian
Midelfort (In 1957 he published
“The Family In Psychotherapy”)
and Nathan Ackerman (In 1958 he
published “The Psychodynamics
of the Family”).
IN 1960’S
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
strategic therapy, structural
therapy, and slightly later, the
Milan systems model.
Salvador Minuchin,
psychoanalytically trained
psychiatrist largely responsible
for the development of the
structural school of family
therapy.
A therapist using this model sees
that family problems are related
to their structure.

1970’s
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

1980’s
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
Family Therapists
Leaders
Alfred Adler-Rudolf Driekurs-open
forum Child Guidance Clinics
Murray Bowen-Multigenerational
Model-Triangulation,
Differentiation of Self
Virginia Satir-Conjoint Family
Therapy-Human Validation,
Relational Family Therapy

Carl Whitaker-Experiential
Symbolic Family Therapy-
therapist or coach influences
change
Salvador Minuchin-Structural
Family Therapy-create structural
change
Jay Haley-Strategic Family
Therapy-solves problems now
Cloe Madanes(Wife of Haley)-
 EVOLUTION OF FAMILY
THERAPY IN INDIA
Family therapy was started in
India about the same time that
Nathan Ackermann initiated it in
the west.
The father of family therapy in
India, Dr. Vidyasagar, started
treatment with the families for
patient who attended the
services of the Amritsar mental
According to him involvement of
family decreased hospital stay,
increased acceptance of the
patient and enhanced family
coping (Vidyasagar 1971).
Following these rewarding two
centres in India- mental health
centre Vellore and national
institute of mental health and
Neuro sciences (NIMHANS)
Bangalore started similar
The mental health centre at Vellore
has facilitate for families to live with
the patients in small cottages
(Varghese 1971)
At NIMHANS where the relatives were
asked to stay with the patient in open
wards (Narayanan et al 1972)
The success of these approaches
culminated in the building of the
family psychiatric centre at NIMHANS
in 1977 where the whole family could
stay in unit family rooms and undergo
FAMILY PSYCHIATRIC
CENTRE AT NIMHANS
The family psychiatric centre is
essentially a referral centre and
families are seen in therapy
either as outpatient or inpatient.
The patient and their families are
referred from six adult psychiatry
units, child guidance centres,
and neurological services or
outside agencies.
FAMILY

A family is defined as two or

more persons who reside
together; share economic
resources; are related by birth,
marriage, or adoption; and or
who have a commitment to each
other over time.
(Walsh
1993)

NORMAL FAMILY
FUNCTIONING
Baranhil suggested that healthy
families can be distinguished
from dysfunctional ones on the
basis of dimensions

 Identity Process
Individuation Vs Enmeshment
Mutuality Vs Isolation

Change
Flexibility Vs Rigidity
Stability Vs Disorganization
 Information Processing
Clear Vs Unclear Or Distorted
Clear Vs Unclear Roles or Role
conflict

 Role Structuring
Role reciprocity Vs Unclear or
conflicted role
Clear Vs Diffuse or Breached
Intergenerational boundaries

 ELEMENTS OF ASSESSMENT
OF FAMILY FUNCTIONING
ELEMENTS OF ASSESSMENT FUNCTIONAL DYSFUNCTIONAL

Clear Indirect,
,direct, open vague,
and honest controlled ,
Communication with with many
congruence double blind
between messages
verbal and
non verbal
ELEMENTS OF ASSESSMENT FUNCTIONAL DYSFUNCTIONAL

Supportive, Unsupportive,
loving, blaming,
Self concept praising, “put-downs”,
reinforcement approving refusing to
with allow self
behaviors responsibili
that ty
instill
confidence
ELEMENTS OF ASSESSMENT FUNCTIONAL DYSFUNCTIONAL

Family Flexible, Judgmental,

members realistic rigid,
expectation and controlling ,
individualiz ignoring
ed individualit
y
ELEMENTS OF ASSESSMENT FUNCTIONAL DYSFUNCTIONAL

Handling Tolerant, Attacking,

differences dynamic, avoiding,
negotiating . surrendering
.

Family Workable, Contradictory,

interactional constructive, rigid, self-
pattern flexible and defeating , and
promoting destructive
needs of all
members
ELEMENTS OF ASSESSMENT FUNCTIONAL DYSFUNCTIONAL

Family Trusting, Distrusting,

climate growth emotionally
promoting painful, with
caring, absence of
general hope for
feeling of improvement
well being
HEALTHY FUNCTIONING
FAMILIES
They have the ability to
communicate thought and feelings.
In the healthy functioning families no
single member dominates or control.
Healthy families have a clear, flexible
power structure with the most
competent members having the most
power.
Families which are cohesive and
adaptable best serve the functions of
 DYSFUNCTIONAL
FAMILIES
Dysfunctional families are often
disengaged (isolated from one
another) or enmeshed (overly
involved with one another).
Multigenerational transmission of
problems are common (i.e.
Grandmother, mother, daughter all
have been sexually and physically
abused)
 I). COMMUNICATION
a) Making Assumptions
 With this behavior one assumes that
others will know what is meant by an
action or an expression or other hand
assumes to know what another member
is thinking or feeling without checking to
make certain.


E g: a mother says to her teenage



daughter “you should have known that I

expected you to clean up the kitchen
b) Belittling feelings


 This Action involves ignoring

or minimizing another’s feeling
when they are expressed.
This encourages the individual to
with hold honest feelings to
avoid being hurt by the negative
response.

c) Failing to listen


 With this behavior one does

not hear what the other
individual is saying. This can
mean, not hearing the words by
“tuning out” what is being said
or it can be “selective
listening”, in which person
hears only a selective part of the
message or interprets it in a
selective manner.
E.g. Father explains to son” if the
contract comes through and I get
new job, we will have a little
extra money and we will consider
sending you to US” Johnny relays
the message to his friend, “dad
says I can go to us”

d) Communicating Indirectly


This usually means that an

individual cannot present a
message to receiver directly so
seeks to communicate through a
third person.
E.g. father does not want his
teenage daughter to see a certain
boyfriends but wants to avoid
angry response from his daughter
if he tells her so. He expresses his

e)Presenting double minded
message
Double blind communication conveys a
“damned if I do damned if I don’t”
message.
E.g. Father tells his son he is spending
too much time playing football, and as
a result, his grades are falling. He is
expected to bring his grades up over
next nine weeks or his car will be taken
away. When the son tells the father he
has quit the football team so he can
study more, dad respond angrily “I
 II). SELF CONCEPT
REINFORCEMENT
a)
 Expressing denigrating
remarks
These remarks are commonly
called “put downs”. Individual
receive messages that they are
worthless or unloved.
E.g. when child spills a glass of
milk accidentally, the mother
responds “you are hopeless! How
b)Withholding
 supportive
messages
Family members find it difficult
provide others with reinforcing
and supportive messages.
E.g. a little boy was playing
cricket, after the game he says
to father “did you see my play?”
dad, “yes I did, son, if you had
been paying better attention you
c) Taking over


 This occurs when one family

member fails to permit another
member to develop a sense of
responsibility and self worth by
doing things individually.
 E.g. Son says “Dad, I got my
driving license last week and
today I will drive my car” Dad
replied “No , no I will drop you
III). FAMILY MEMBERS
EXPECTATIONS
a) Ignoring individuality


This occurs when family member s

expect others to do things or behave
in ways that do not fit with the
latter’s individuality or current life
situation.
E.g. Robert wants to do job in a
newspaper company after his
studies. But his father asked him to
take over the family business
founded by his grandfather. Robert
sees this as a betrayal of the family.
b) Demanding proof of love


Family members place

expectation on others behaviour
that are used as standard by
which the expecting member
determines how much the other
member care for him or her.
E.g. “if you will not be as I wish
you to be, you don’t love me”.

IV). HANDLING
DIFFERENCES
a) Attacking
A different opinion can
deteriorate in to a direct
personal attack and may be
manifested by blaming other
person.
b) Avoiding

With this tactic, differences are

never acknowledged openly.
c) Surrendering


The person who surrenders in the

face of disagreement does so at
the expense of denying his or
her own needs or rights.

V). FAMILY
INTERACTIONAL
PATTERNS
a) Patterns that causes


emotional discomfort
Interactions can promote hurt
and anger in family members.
These interactional patterns
include behaviours such as never
apologizing or never admitting
that one has made mistake,
forbidding flexibility in life
situations.
 b).Factors that intensify
problems rather than
solve them
When problems go unresolved over a
long period of time, it sometimes
appear to be easier it to ignore them.
If problems of the same type occur, the
tendency to ignore them then
becomes the safe and predictable
pattern of interaction for dealing with
this type of situation.
This may occur until the problem
intensifies to a point at which it
can no longer be ignored.
c) Patterns that are in conflict


with each other

Some family rules may appear to
be functional workable and
constructive on the surface but
in practice may serve to destroy
healthy interactional pattern.

 Others
Marital schism (split)


Family in a constant state of

disequilibrium through repeated
threats of parental separation and
communication
masks conflicts
Parents disqualify each other and
join with children excluding the
partner.
Marital skew (twist)


 Parental relationship is
distorted; Relationship is not
under threat, due to one
excessively powerful and
dominant parent.

Pseudo-hostility and Pseudo-


mutuality
Disjointed or fragmented
communication leads to disrupted
interactions. Pressure is put on the
child to avoid family relationships.

Mystification (confusion)


Mystification occurs when one or

more family members fail to
understand the meaning, purpose of
communication from another
member; especially a parent.
The communication received is often
deliberately vague.
The vague communication places the
mystified person in an inferior
position and leads to powerlessness.

Triangulation


Occurs when a third person is

brought into a dyadic
relationship to de-intensify a
dispute between two people
(generally the parents);
Communication occurs through a
third person.
The Elephant in the Room


The problem that no one wants/dares

to talk about and the problem are
clearly visible to all involved; Fear of
retaliation or negative consequences
and shame often keep individuals
from discussing the problem. Self
blame is common. Victims continue
to allow the problem to exist and not
be discussed. (E.g. alcoholism,
sexual abuse)
Lack of Differentiation


Autonomy is important for all

individuals.
It represents the degree of
independence that an individual
needs to function apart from
others in a system. Fusion is the
absence of autonomy;
Lack of differentiation leads to
enmeshment with others.
Scapegoating


 Families often scapegoat one

individual for all of the family’s
problems.
Lack of Boundaries


All individuals need boundaries.

The absence of boundaries
produces unclear limits in terms
of what others may or may not
say or do to a person. Without
boundaries abuse can easily
occur.
FAMILY THERAPY
 DEFINITION
 A type of therapeutic modality in
which the focus of treatment is on the
family as a unit; it represents a form
of intervention in which the members
of a family are assisted to identify and
change problematic, maladaptive, self-
defeating, repetitive relationship
patterns.
 (Goldenberg & Goldenberg, 2005)
 DEFINITION
Family therapy is a branch of
psychiatry that sees an
individual’s psychiatric symptoms
as inseparably related to the
family in which he lives.
 (Susan H McCrone, Anne H
Shealy)
DEFINITION
A type of psychotherapy
designed to identify family
patterns that contribute to a
behavior disorder or mental
illness and help family members
break those habits.
 (Webster’s new world medical
dictionary)

GOALS OF FAMILY
THERAPY
Help families become aware of their
needs.
Provide genuine, enduring healing
Shift power to parental figures
Improve communication
Make interpersonal, intrapersonal,
and environmental changes
Keep substance abuse from moving
from one generation to another
Provide a neutral forum to solve
problems
MAJOR FAMILY THERAPY
APPROACHES
Structural
Strategic
Cognitive-Behavioral
Social Constructionist
Experiential
Object Relations
Multigenerational
Narrative

BASIC THEORETICAL
CONCEPTS
Psychodynamic theory

Ackerman (1956) introduced
the idea of “interlocking
pathology”, arguing that the
psychopathology of the different
members of the family fitted
together to produce the family
system, which the therapist
encountered.

Group therapy
 The aim is to help the members
of the group gain insight through
the process of group interaction.
 The therapist’s role is
principally that of facilitator and
sometimes interpreter of what is
happening between the group
members.

 Other theories
a) Cybernetics


Cybernetics is a term that was

introduced by Weiner (1948) to
describe regulatory systems that
operate by means of feedback
loops.
This process requires a receptor of
some sort, a central mechanism
and an effecter. These are
connected to form a feedback loop.
Cybernetics concerned with the
study of feedback mechanisms
in systems. Two types of
feedback loops:
Negative, signals the system
to restore the status quo
Positive, signals the need to
modify the system.
 Both types result in

homeostasis.
b) Systems theory
General systems theory was
proposed by Von Bertalanffy,
defined ‘a complex of interacting
elements’
Hall and Fagan (1956)
definedsystem as ‘a set of
objects together with the
relationship between the objects
and between their attributes.’
There are two systems
Closed system is those in which
there is no interaction with the
surrounding environment and
shows “entropy”.
Open systems such as families
do not show “entropy”. There is a
steady inflow and out flow of
relevant information across the
boundary of the system.
The relationship between
supra systems, systems and
subsystems
 Ideas and concept of
system theory
Families and other social groups are
systems having properties which
are more than the sum of the
properties of their parts.
The operation of such system is
governed by certain general rules
Every system has a boundary
The boundaries are semi permeable
(something can pass through, others
cannot or certain material can pass
one way but not the other)
Family systems tend to reach
relatively, but not totally steady
states. Growth and evolution are
possible. Change can occur or
stimulated in various ways
Communication and feedback
mechanisms between the parts of a
Events such as the behaviour of
individuals in a family are better
understood as examples of
circular causality rather than as
being based on linear causality.
Family systems appear to be
purposeful
Systems are made up of
subsystems and themselves are
part of supra systems.

Characteristics of systems:

Circular causality
1.
 Linear causality describes the
process whereby one event
causes another.
2. Boundary

 Every system has a boundary,

which mark it off from
surroundings. They control
emotional interchanges, closeness
3.Feedback
4. Equifinality
 The Process by which an open
system maintains the same
steady state with differing inputs.


 c) Learning Theory
Respondent conditioning
This changes the behavior by altering

the circumstances leading up to it.

E.g. Pavlov’s classical experiment with

dog
Operant conditioning

It Changes the behaviour by altering the

circumstances following it.

E.g. If person touches hot and get

burned that person is less likely to

touch the same thing again.
d) Communication
theories
a) It is impossible not to
communicate
b) Communication has a relationship
aspect
c) Punctuation is the important
feature of communication
d) Communication may be dividing
into digital and analogical varieties
e) Communication is symmetrical
and complementary interaction

 SCHOOLS OF FAMILY
THERAPY
PSYCHOANALYTICAL FAMILY
THERAPY

Murray Bowen and Virginia Satir
is prominent therapist who has
made use of psycho analytical ideas
in their work.
 The family members are
encouraged to ‘free associate’,
that helps their thoughts to flow
freely without conscious censorship,
Psycho analytic therapist
generally makes fewer
comments, asks fewer questions
and intervenes less actively. They
usually refrain also from giving
advice and form actively
manipulating the families they
treat.
BEHAVIORAL FAMILY
THERAPY
Behavior therapist applies the
principle of learning theory in
treatment of families.
Change in families
conceptualized in terms of
respondent conditioning, operant
conditioning modeling or
cognitive change.
The “behavior analysis”
enables the therapists to
develop a plan to alter the
contingency or circumstances
and cognitions often by direct
intervention in the family.
GROUP THERAPY APPROACHES
 The family therapists have
used some of the approaches of
group therapy the role of a
therapist is facilitator and
sometimes interpreter of what is
happening between the group
members.
 Family members can certainly
learn the value from each other in
a group therapy setting.
FAMILY SYSTEM THERAPY
MAJOR CONCEPT
Differentiation of self


Differentiation of self is the ability to

define oneself as a separate being.
Healthy families encourage
differentiation.
A person with well differentiated self
recognizes his realistic dependence
on others, stay calm and clear
headed in enough in the face of
conflict, criticism.
Triangles


The concept of triangle refers to a

three personal; emotional
configuration that is considered
the building block of the family
systems.
Triadic interaction configurations
which are the basic building block
of any emotional system. When a
two-party system becomes
unstable because of anxiety, a
third person is involved to stabilize
Nuclear family emotional


process
The nuclear family emotional
process describes the patterns of
emotional functioning in single
generation.
Lower the level of differentiation,
the greater the possibility of
problem in the future.

Family projection process
Couples are unable to work
through ‘un differentiation’ or
fusion that occurs with
permanent commitment may
when they become parents,
project the resulting anxiety on
to the children.

Multigenerational
transmission process
Interactional patterns are
transferred from one generation
to another. Attitudes, values,
beliefs, behaviors and patterns
of interaction are passed along
from the parent to children over
many lifetimes. So certain
behaviors are existed within a
family through multiple
generations.
Genograms
It gives a picture of three or more
generations (like a family tree)
and notes important family
dynamics, rules, patterns,
mental health issues, etc.
 Goal and Technique of
the Therapy
1) To increase the level of differentiation
of self, while remaining in touch with
the family system.
2) The intense emotional problems
within the nuclear family can be
resolved only by resolving
undifferentiated relationship.
3) Emphasis is given to understanding
the past relationship
Therapeutic role is that of a “coach” or
supervisor
 Therapeutic techniques
include:
1)Defining and clarifying the
relationship between the family
members
2) Helping family members develop
one to one relationship with each
other and minimizing triangles within
the system
3) Teaching family members about the
functioning of emotional systems.
4) Promoting differentiation by
THE STRUCTURAL FAMILY
THERAPY
MAJOR CONCEPTS
 Transactional patterns
These are the rules that have
been established over time that
recognize the ways in which
family members relate to one
another.
 Subsystems
Subsystems are smaller elements
that make up a large family
system. Subsystem can be
individuals or can consist of two
or more persons united by
gender, relationship, generation,
purpose.

 Boundaries
 Define the level of
participation and interaction
among subsystems. Boundaries
are appropriate when they
permit appropriate contact with
others while preventing
excessive interference. Clearly
defined boundaries promote
adaptive function. Maladaptive
functioning can occur when
boundaries are rigid or diffuse.
A rigid boundary is characterized
by decreased communication and
lack of support and responsiveness.
Rigid boundaries prevent
subsystem from achieving
appropriate closeness or
interaction with others in the
system, rigid boundaries promote
disengagement, or extreme
separateness among family
members.
Diffuse boundaries are
characterized by dependency or
over involvement. In interferes
with adaptive functions because of
over investment, over
involvement, lack of differentiation
between certain subsystems.
Diffuse boundaries enmeshment or
exaggerated connectedness
among family members
GOAL AND TECHNIQUES
OF STRUCTURAL FAMILY
THERAPY
Goal of structural family therapy
is to facilitate change in family
structure
Goal is to restructure the family
system to create clear and
flexible boundaries
 Techniques
 Joining the family.
The therapist must become the part
of the family if restructuring is to
occur.
The therapist joins the family but
maintains leadership position.
He or she may at different times
join various subsystems within the
family but ultimately includes the
entire family system as a target of
 Focusing
Exploring specific areas

 Evaluating the family
structure


Even though a family may come for a

therapy because of behaviour of one
family member, the family as a unit is
considered problematic.
The family structure is evaluated by
assessing transactional pattern
system flexibility, potential for
changing boundaries, family
developmental stage and role of the
identified patient within the system
Enactment
Therapist has family enact an
interaction to enable the family to try
different ways of interacting 
Intensification 
Therapist increases the emotional
aspects of interactions
Unbalancing     
Conscious attempt to form a coalition
with one member against another or
supporting one member at the
expense of another to throw the family
system off balance
 Restructuring the family.
An alliance or contract for
therapy is established with the
family by becoming an actual
member of the family, the
therapist is able to manipulate
the system facilitate
circumstances and experience
that can lead to structural
change.

 THE STRATEGIC FAMILY
THERAPY
The strategic model the family
therapy uses the interactional or
communication approach.
In this model families considered
functional are open system where
clear and precise messages,
congruent with the situation, are
sent and received. Dysfunctional
families are viewed as partially
closed systems in which
communication is vague.
 MAJOR CONCEPT
Double blind communication
 Double blind communication occur s
when a statement is made and
succeeded by a contradictory
statement. It also occurs when a
statement is made and accompanied
by nonverbal expression that is
inconsistent with the verbal
communication. Double blinded
communication often results in a
“damned if I do damned if I not”.
Pseudo mutuality and pseudo


hostility
Pseudo mutuality is characterized by
façade (image, face) of mutual
regard. Pseudo mutuality allows
family member to deny underlying
fears of separation and hostility.
Pseudo hostility is also affixed and
rigid style of relating, but the facade
being maintained is that of a state of
conflict and alienation among family
members to deny underling fears of
Marital schism (split)
 Family in a constant state of
disequilibrium through repeated threats
of parental separation and
communication masks conflicts,
Parents disqualify each other and join
with children excluding the partner.
Mutual trust is absent and competition
exists for closeness with the children.
Often partner establishes an alliance
with his or her parents against the
spouse. Children lack appropriate role
Marital skew (twist)
 Parental relationship is
distorted; Relationship is not
under threat, due to one
excessively powerful and
dominant parent. There is a lack
of equal partnership. The
marriage remains intact as long
as the passive partner allows the
domination to continue. Children
also lack role models when a
GOAL AND TECHNIQUES
OF THERAPY
To create changes in destructive
behaviors and communication
patterns among family members.
Therapeutic techniques
involve:
1.Paradoxical intervention
A paradox can be called a
contradiction in therapy or
“prescribing the symptom.”
The therapist requests the family
to continue to engage in the
behavior that they are trying to
change.
Reframing (positive
reframing. )
Re labeling a problematic behaviour by
putting into a new, more positive
perspective that emphasizes its good
intention. With reframing, the
behaviour may not actually change,
but the consequences of the may
change owing to a change in meaning
attached to the behaviour

NARRATIVE FAMILY THERAPY

The goal of therapy is to

transform clients’ stories and
alter their identities.
The centerpiece of therapy is
questioning.
APPLICATIONS OF FAMILY
THERAPY
Common child psychiatric
disorders
Child abuse
Eating disorders, esp.
anorexia nervosa
Depression
Schizophrenia
Marital and family distress 

 BASIC CRITERIA FOR
EMPLOYING FAMILY
THERAPY
Evidence of malfunctioning family group
Evidence that family dysfunction is
related to the problems for which help
is being sought.
When a change is desired in the way a
family functions
Separation difficulties
Family functions at the paranoid
schizoid level
Severely disorganized families,
DIFFERENCE BETWEEN
INDIVIDUAL THERAPY
AND FAMILY THERAPY
INDIVIDUAL THERAPY FAMILY THERAPY
View the individual as Relationships are the
the agent of change agents of change

Ask, why? Ask, what?

Think linearly (A Think circularly (A and
causes B) B mutually influence
one another.)
INDIVIDUAL THERAPY FAMILY THERAPY
Treat the “mind” Treat the interactions
between individual

Focus on the past Focus on the present

Focus on content Focus on process

Recognize individual Recognize individual and

developmental familial development
trajectories

Obtain accurate Explore System for

diagnosis DSM IV family process & rules
INDIVIDUAL THERAPY FAMILY THERAPY
Begin Therapy right now Invite in parents,
siblings

Focus on : causes, Focus: family

purposes, processes relationships

Concern with individual Concern trans

experience & generational meanings,
perspective rules
Intervene to help Intervene to change
individual learn to cope context within family
system
LIMITATIONS OF FAMILY
THERAPY

Individual psychological factors

were neglected.
Lack of clear operationalization of
the constructs for research
purposes
Feminist Critique
Race/Ethnic Diversity
ROLE OF NURSE
Nurse should be well prepared to
enhance family functioning in
traditional clinical setting and
nontraditional setting
The knowledge skill and creativity of
the nurse enhances family
compliances
Nurses need to integrate theory and
interventions into clinical programs,
advocate for family and third party
reimbursement for family
Thank you