Clinical Psychology Of Family Therapy Research Paper

1. Historical Perspective Of Family Therapy

1.1 Evolution Of The Field

Social work, psychiatry, and psychoanalysis in both Great Britain and the United States all made enormous contributions to the development of family therapy. In her influential book Social Diagnosis (1917), Mary Richmond was one of the first proponents of studying the whole family and its needs. At the same time, the dominance of the psychoanalytic model in the mental health field focused on the mother–child dyad as the source of psychopathology. This model, with its linear–causal attributions, blamed maternal deficiencies for any childhood disturbance. Adler became the first of Freud’s pupils to openly challenge such an explanation of human behavior. He offered an alternative and more socially rooted theory of psychodynamics, organized child guidance clinics in Vienna, and counseled children, parents, and teachers.

By the 1930s, a strong community of analysts had developed in the United States. Among the most influential to emerge was Harry Stack Sullivan. He focused on interpersonal relations in his research into family dynamics of schizophrenia. By the time family therapy pioneers began to experiment in the 1950s, there was a well-established bias toward social explanations among American analysts. This trend was underscored by a paradigm shift that occurred with the development of General Systems Theory (GST). GST implies that family therapy is grounded in a set of assumptions about the interchange between individual, family and social processes, which operate according to certain principles that apply to all human systems (Bateson 1971). Family members are interrelated such that every individual affects each other, while the group as a whole affects the first member in a circular chain of influence, making every action in a sequence also a reaction.

1.2 Pioneers Of The Family Therapy Movement

John Bowlby’s work at the Tavistock Child Guidance Clinic in London during the late 1940s exemplifies the transition from an individual to a family approach. These beginnings of family therapy were tentative in that Bowlby felt he had to ‘reassure’ readers that family interviews were ‘rarely employed.’ However, family interviews prior to the initiation of treatment became routine, and served as a major stimulus to the development of this new approach in the United States. By the end of the 1950s family therapy emerged as a connected movement whose members exchanged correspondence and visits, and began to cite one another.

Nathan Ackerman came to family therapy from the field of child psychiatry. His involvement in a study of mental health problems among the unemployed, along with other experiences, convinced him that both the environment and the psyche could influence emotional problems. Although family interviews began as an experiment for Bowlby, Ackerman saw this as the major form of treatment in child guidance clinics. He saw the family as the unit of diagnosis and treatment, and began sending his staff on home visits to study families.

In 1958 Ackerman published the first book-length treatment of family relationships, The Psychodynamics of Family Life. By 1961 family therapists met to prepare the way for the first joint handbook and to found a common journal, Family Process. In addition, John Bell’s respected monograph, Family Group Therapy (1961), constituted one of the founding documents of the profession. Carl Whitaker, who is noted as the most brazen of the founders, is generally credited with having called the first formal meeting in the family therapy movement in 1953. As family therapy developed, he played an integral role, as evident from his membership on the first board of editors for Family Process.

Among the pioneers, Lyman Wynne was particularly well prepared by formal training to become a family researcher and therapist. After his medical training in 1948, he embarked on doctoral studies in the Department of Social Relations. As a graduate student, he came into contact with many of the leaders in the field of sociology, social psychology, and social anthropology. Initially, he saw whole families only when individual treatment or joint interviews with the mother and patient were not effective. Gradually, however, he worked out his own theory of the family structure of schizophrenic patients. Murray Bowen, a psychiatrist who specialized in schizophrenia, felt that the parents—in particular, mothers, should be required to live in the hospital with their disturbed child. In 1954 he joined Lyman Wynne at the National Institute of Mental Health, where he established a program for treating families together.

The Palo Alto Group has probably one of the strongest claims to have been at the forefront of the development of family therapy. This group consisted of five richly individual persons, viz. Gregory Bateson, Jay Haley, John Weakland, Don Jackson and Virginia Satir. Bateson, an anthropologist and philosopher by training, and considered by many as the founder of family therapy, wrote important works such as Steps to an Ecology of Mind (1971) and Mind and Nature (1979). Bateson and his group hypothesized that family stability is achieved by a feedback system, i.e., whenever the family system is disturbed, it will quickly move toward reestablishing balance homeostasis. In 1956 this group generated one of the most discussed papers in the history of psychiatry. In ‘Toward a Theory of Schizophrenia,’ they introduced the concept of double-bind as the crucial familial determinant of schizophrenia in children. Jackson published a seminal paper on conjoint family therapy, arguing that it was more effective than seeing family members individually (Jackson 1959). At the same time he founded the Mental Research Institute (MRI), and invited Satir to join him. The MRI, compared to the original Bateson group, was more focused on the treatment of families as opposed to research.

The influence of behavioral family therapy can also not be overlooked as it was launched as a specialist area in the late 1960s with the seminal work of Stuart (1969) and Liberman (1970). Behavioral approaches to family therapy can be characterized as goal oriented, a general reliance on principles of learning, directedness in interventions, and preference for short-term, problem-solving involvement.

While the pioneers dominated the 1960s and 1970s, they also saw new innovations. One innovator who has taken his place among the founders as one of the most influential of all family therapists is Salvador Minuchin. In the late 1960s he became the director of the Philadelphia Child Guidance Clinic and convinced Jay Haley, among others, to join him. The Minuchin– Haley team made substantial clinical and methodological contributions. ‘Structural therapy’ emerged from their interaction, and will be discussed below. In addition to carrying over the communications and systems elements developed at MRI, Minuchin and Haley gave added emphasis to the realignment of counterproductive family coalitions, and tied their theory to a family developmental framework.

2. The First Family Therapy Models

The field of family therapy encompasses many modalities, each with distinctly different ways of conceptualizing and treating families.

2.1 Psychodynamically Oriented Family Therapy

Nathan Ackerman was among the first to integrate psychoanalytic principles with systems theory. He viewed individual functioning as a reflection of constant interactions between the individual, the family, and society. For Ackerman, understanding a person requires an understanding of their intrapsychic processes and interpersonal interactions. Achievement of this goal involves helping family members adopt social roles that are flexible so as to permit role complementarity.

Murray Bowen’s Extended Family Systems Therapy expands GST beyond the nuclear family. Behavioral disorders are the result of a multigenerational transmission process in which progressively lower levels of differentiation, i.e., independence of self from others, occur as the family’s lack of differentiation is transmitted from one generation to the next. The primary goal of therapy is to increase the differentiation of family members. Bowen regards family relationships as involving ‘triangles,’ and therapy typically includes only two family members (usually the spouses) while the therapist becomes the third member in a ‘therapeutic triangle.’ As long as the therapist remains objective and neutral (does not become emotionally triangled), his her presence helps family members resolve the fusion between them and achieve higher levels of differentiation.

Contemporary proponents of psychodynamically oriented family therapy include Christopher Dare, John Byng-Hall, and James Framo.

2.2 Problem-Solving Approaches To Family Therapy

2.2.1 Communication Interaction Approach. This approach to family therapy grew primarily out of research conducted by Gregory Bateson and his colleagues. They recognized the importance of communication in family and individual dysfunction (e.g., the role of ‘double-bind’ communication in the development of schizophrenia), and developed a school of family therapy based on the principles of communication. This approach incorporates principles derived from information theory, cybernetics, and GST. Family therapists adopting this approach accept a circular model of causality that regards a symptom as both a cause and an effect of dysfunctional communication patterns. Although therapists do not deny that individual intrapsychic factors underlie family problems, the observable interactions between family members are viewed as appropriate targets of therapy. The primary goal of therapy is to alter interactional patterns that maintain the presenting symptom(s).

2.2.2 Structural Family Therapy. Salvador Minuchin (1974) originally developed structural family therapy through his work with poor, inner-city populations. In his seminal work, Families and Family Therapy, he argued that symptoms are the result of family structural imbalances. Structural family therapy focuses on concepts that describe space configurations: for example, malfunctioning hierarchy and boundaries, and maladaptive reactions to developmental and environmental changes. Structuralists use the key notion of ‘complimentarity’ to denote a fit among matching parts of a whole. Symptomatic behavior is seen as one such part that fits into a dysfunctional whole organization. For instance, an adolescent’s anorexia nervosa may be related to a mutual invasion of the patient’s and their parents’ territories. In a dysfunctional family, development has been replaced by inaction. When a family is stuck in a rigid arrangement, they cannot solve their problems and continue to grow.

Breaking away from such an organizational impasse requires the mobilization of resources that the family already latently possesses and which are often apparent in a different context. Systemic change, in the structural view, equals an increase in the complexity of the structure—an increment in the availability of alternative ways of transacting. The function of the therapist is to create a context for the family to experience these alternative patterns as accessible, possible, and necessary. What the structural therapist is trying to build through his or her restructuring efforts is more important than what he or she is trying to uncover. The therapist does not emphasize individual change or the prescription of specific solutions. Instead, he she attempts to reorganize the family structure, or increase its flexibility. Through parental leadership and the creation of clear subsystems and boundaries, more adaptive coping is promoted.

2.2.3 Strategic Or Systemic Family Therapy. In addition to the strategic and systems models of the Palo Alto group, other innovative early approaches were Jay Haley (1976) and Cloe Madanas’ (1981) problem-solving approach, and the Milan team approach (Selvini-Palazzoli et al. 1978). Haley and Madanas are now most associated with strategic family therapy, which combines the communication interaction approach with Minuchin’s structural family therapy. Haley coined the term ‘strategic therapy’ when describing the techniques used by the psychiatrist Milton Erickson. Like communication interaction therapists, strategic therapists emphasize the role of communication in maladaptive behavior, but their focus is on how communication is used to increase one party’s control in a relationship. Whereas struggles for control are inherent in any relationship, they become pathological when one or both parties denies his her intent to control the other person, and when this results in symptomatic behavior. Symptoms are thus seen as interpersonal phenomena rather than intrapsychic events. The focus in strategic therapy is not on understanding the source of problems, but on alleviating current symptoms through altering family organization, hierarchy, and generational boundaries.

The Milan team consisted of Mara SelviniPalazzoli, Luigi Boscolo, Gianfranco Cecchin, and Giuiana Prata. Their book, Paradox and Counterparadox (1978), presented the conceptual framework and methodology of their systemic family therapy. Stimulated by Bateson’s writings (Bateson 1971), the Milan group radically revised their analysis of systems. Until this point, they had seen the therapeutic process as one wherein the therapy team observed the family system in order to understand it. Working as a team, utilizing a one-way mirror, circular interviewing, and employing systemic analysis to describe the family’s interactional map, interventions were designed to ensure that the therapist remains separate from the family. This analysis and approach was labeled ‘firstorder cybernetics.’

Through revisiting Bateson’s work, the Milan clinicians began to take into account the context of observation itself, and hence the observational system as well. In first-order cybernetics a distinction is arbitrarily drawn between the family and the therapist, as though they were two distinct systems. The Milan clinicians began to see the family in the context of the therapist’s interaction with them. This new awareness included a second level of observation that parallels the first. This second level of observation is that of the system created by the interaction between the therapist and family within the therapeutic encounter. This second level observation was termed ‘second-order cybernetics.’ Instead of only studying the interactional patterns of family members, the feedback loops that develop between interviewer and interviewees were also considered.

3. Recent Family Therapies

The 1980s ushered in a new stage in the development of family therapy, in part inspired by the Milan group. First, an era of skepticism and a reexamination of the old, under the banner of postmodernism, emerged. Postmodern psychologies concern themselves with how people make meaning in their lives; how they construct reality. Constructivism (how an individual creates his her own reality) and social constructionism (how social interaction creates reality) took hold of family therapy in the early 1980s and have since exerted a powerful impact on the field. Second, a movement to deconstruct established knowledge expanded in the form of feminist critique. This exposed the patriarchal bias in the assumptions and practices of many family therapies (Hare-Mustin 1986). Third, postmodern family therapy became more collaborative, which led to a cross-fertilization among therapists, as well as between therapists and families. Fourth, the mechanistic aspects of systems thinking have become less popular. Instead the focus has shifted to the stories that govern a family’s life rather than its structure or interactional sequences of behavior. Fifth, postmodernists have become less wedded to universal patterns, and emphasize diversity and pluralism.

The result of this review has been the realization that a favored therapeutic approach may only be one of many useful approaches. The field of family therapy has also shifted its view of the family as the source of symptoms to a biopsychosocial view. From this perspective, assessment and intervention attend to the impact of biologically based conditions as well as larger cultural influences, such as race, class, gender, ethnicity, religion, and sexual orientation on the family. Family therapy today is characterized as having a resource perspective as opposed to concentrating on deficits within the family. It has also shifted from a model of the therapist as expert to one of respectful collaboration with family members. Assessment and intervention have shifted their emphasis on problems and how they are maintained to the attainment of solutions (Walsh 1993).

3.1 Postmodern Approaches

Growing out of the strategic systemic models, the post-Milan or ‘second-order’ family therapists invented techniques to engage families in ‘conversation’ about their problems; these are known as narrative (White and Epstein 1990) or conversational approaches (Anderson and Goolishian 1988). These therapies are based in constructivist and social constructionist views of reality. Normality is viewed as socially constructed. In narrative therapy, for instance, the therapeutic conversation and process of ‘restorying’ a problematic experience is emphasized. The goal is to envision optimistic life stories that are more empowering and satisfying. Another constructivist approach that has gained popularity is Steve de Shazer’s solution-focused therapy (Berg and de Shazer 1993). This is similar to the narrative approach in that it uses leading questions to separate clients from their problem-focused stories. The therapist is affirmative in that he she deconstructs the problem story by having clients focus on exceptions, i.e., times when their problem did not occur. No judgments are made about the solutions a family may discover. Goals in these therapies are achieved by externalizing problems, focusing on future-oriented potential, and the search for exceptions and unique outcomes.

3.2 Psychoeducational Approaches

The psychoeducational model was developed for family intervention with schizophrenia and other persistent mental and physical illnesses (Falloon et al. 1984). In schizophrenia, for instance, family management of the illness has been demonstrated as effective in reducing levels of ‘Expressed Emotion’ and lowering rates of relapse. Family therapy, combined with drug maintenance and social skills training, has produced the best results by reducing relapse rates and improving functioning. The process of change is facilitated through information and management guidelines, social support, and a respectful collaboration between therapist and family.

4. Research In Family Therapy

The roots of family therapy are in research, as many founders came to this field through studying interactional patterns associated with problem families. Initially, no distinctions were drawn between researchers and therapists, as research had direct clinical relevance, and hypotheses were developed and tested in clinical settings. The growth in research depended disproportionately on intuitive appeal as opposed to evidence. This research was mainly qualitative and impressionistic in nature.

Since the early investigations, research in family therapy has grown dramatically and undergone at least two major transformations (Sprenkle and Moon 1996). First, the field has evolved from an impressionistic to a quantitative emphasis. This shift forced family therapists to operationalize less well-defined concepts, and to develop more reliable and valid measures. The early decades were characterized by a strong push for outcome research and, although the scientific rigor of some of the earlier studies may be questionable, it did give credence to an emerging discipline. Second and more recent, a transformation that is characterized by a shift from quantitative methods to the incorporation of qualitative methods can be discerned. This transformation was facilitated by the advent of the new epistemology constructivism, or social constructionism. Linear causality, assumed by traditional quantitative research, has been replaced by more systemic thinking. Proponents of the second transformation argued that family therapy concepts were operationalized before being truly understood and, consequently, seemed removed from clinical reality. Therefore, the second transformation emphasizes the ‘context of discovery,’ i.e., the intricate subtleties of the therapeutic process, as opposed to the ‘context of verification.’ The integration of outcome and process research that has characterized the first and second transformations, respectively, has gained the support of family therapy researchers. The Maudsley group in London exemplifies this integration with their family treatment studies for eating disorders (Eisler et al. 1997).

This ‘third transformation’ in family therapy research is called pluralism. A pluralistic research community values and appreciates different inquiry paradigms, methodologies and designs, and encourages an atmosphere of understanding, openness, and tolerance. Methodological pluralism encourages research from a wide variety of perspectives, and increases the tools at our disposal for understanding family therapy processes and outcomes (Gurman et al. 1986).

5. Future Directions

Family therapy is generally effective, and family treatments that focus on specific problem areas have been shown to have positive and enduring effects. If treated systemically, problems with clear family relations implications show a greater likelihood of a good outcome. The growing diversity of families poses new challenges for the family therapy field. Culture, class, race, ethnicity, sexual orientation, and religion contribute greatly to family beliefs and practices (Falicov 1995). A broader definition of normalcy has to be considered if family therapy is to remain responsive to this pluralism. Recent shifts from action to narrative, and from challenging to collaborating, have opened new possibilities for doing family therapy. Family therapy has developed greater humility about the influences of existing theoretical models, diminished the need to prescribe to and change people, and increased trust in a family’s own resources.

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