Introduction
Family counseling can be thought of as modifying the relationships in a family to promote harmony. “Family,” in this case, is defined as a system of interlocking triangles that is maintained or changed by feedback. Therefore, the three basic concepts in family counseling are system, triangles, and feedback.
System
According to Buckley (1967), a system is made up of two parts, such that 1) mutual causality affects each of the interconnected and interdependent parts; and 2) the parts are stable with respect to each other. An open system continuously has elements entering and leaving. A family is an example of an open system.
Wholeness, relationship, and equifinality are the three important elements of an open system. “Wholeness” means the system is more than the sum of its parts; it also includes their interactions. Thus, one can understand a given part only after understanding its interactions with the other parts. “Relationship” emphasizes what is happening (in these interactions) rather than why it is happening. The concept that a system has no “memory” has enormous importance for family therapy because it justifies concentrating on the here-and-now. Regardless of the origin of the problem, any difficulty can be removed if a change is made in the system. This quality is called “equifinality.”
Interlocking Triangles
The elements of the family relationship system are a series of interlocking triangles (Bowen, 1971). These interlocking triangles lend stability to counter the emotions found in the family. Thus, a third person or thing can be introduced to restore equilibrium and stability to an unstable, two-party system.
Interlocking triangles can take the form of husband, wife, and hobby, for example. In families with children, interlocking triangles can be formed among the father, mother, and child, as would be the case in the nuclear family (Minuchin, 1974), or among the three generations of a family (grandparents, parents, and children), as proposed by Murray Bowen (1976. Liebman, et al., 1976).
Feedback
The system adjusts itself through feedback, which can be either positive or negative. Negative feedback is used to restore the equilibrium of the system after a deviation from normal system interaction. Positive feedback is used to establish a new pattern of interactions, which it does by preventing a return to the old status quo. Positive feedback might be used by a therapist to push a problem in the “wrong” direction until the system falls of its own weight.
History
As with many forms of therapy, the roots of family systems therapy are found in the works of Freud. Little by little, however, the focus has been changed away from Freud’s approach by the works of therapists such as Alfred Adler, Harry Stack Sullivan, Salvador Minuchin, Lyman Wynne, Don Jackson, Jay Haley, Virginia Satir, and Murray Bowen.
Sigmund Freud
Freud’s work in this field was predominantly concerned with the examination of instincts. Although later he began probing more psychological explanations (including the theory of the Oedipus complex), the psychological aspects of family systems therapy are more the work of object-relation therapists, such as Sullivan, and ego analysts, such as Melanie Klein, Ronald Fairbairn, and Deinz Hartmann (Guntrip, 1971).
Alfred Adler
Adler was perhaps the most influential of the “social thinkers” in therapy, and his work has had an important — albeit indirect — impact on family theory. His thinking on sibling position, for example, became a central concept in a school of family therapy associated with Murray Bowen (1971). Adler claimed that man was a social (rather than instinctual) being, motivated by goals instead of instincts. This meant that context and environment (such as the family constellation) were essential.
Harry Stack Sullivan
Sullivan’s work on schizophrenia led him away from a biological answer, and towards a psychological one. Sensing that the primitive relationship between the mother and child was critical, Sullivan shifted therapy from a purely intrapsychic focus to a more interpersonal focus.
Salvador Minuchin
Minuchin defined the family system as a collection of subsystems: individual, spousal, parental, and sibling. Between the subsystems are boundaries that must be clearly defined for the family to function properly. Dysfunctional boundaries include enmeshed boundaries and rigid boundaries. Minuchin (1974) uses feelings but more as a technique to change the family interaction than by addressing himself to the feelings themselves.
Lyman Wynne
Wynne also worked primarily with schizophrenia, seeing it as internalized representations of the family’s social organization. Wynne saw schizophrenia in balancing the family members’ need to be close with the need to be an individual. Wynne used the term “pseudomutuality” to describe the situation of trying to fit into the family system at the expense of one’s identity. He also used the term “pseudohostility” to describe a superficial split in the family system.
Don Jackson
Jackson was one of the first to apply systems thinking to family therapy. As such, he was very influential with therapists such as Satir and Haley. Jackson’s work emphasizes the cognitive aspects of communication.
Jay Haley
Haley’s main focus is on the tactics of the patient and therapist as they maneuver around each other. These observations lead to discovery of the symptoms, symptoms being the way the patient deals with other people. In contrast with Jackson, Haley emphasizes power struggles in communication.
Virginia Satir
Satir stresses the feeling aspects of communication, unlike most other family systems therapists. For Satir, poor communication is the direct result of poor self-esteem. Like Murray Bowen, Satir sees the need for the individual to delineate a clear identity (maturation).
Murray Bowen
Bowen’s psychoanalytic background belies his current family system approach. Although he subscribes to the concept of triangles, Bowen is adamant that the therapist must not become involved in a triangle with the patients. By eschewing transference, the therapist forces the patients to deal with their problems (tension and anxiety). Bowen also offers an adjunct concept: de-triangling. De-triangling is described by Bowen as a means for the patient to increase the proportion of solid self to pseudo self.
Beginnings
The modern family-therapy movement started in the mid-1950s and focused largely on research into schizophrenia. This produced a series of concepts known under various labels that became the core ideas in family therapy: double bind, stuck-togetherness, schism and skew, pseudomutuality, mystification, and interlocking pathologies.
Current Status
Although family therapy began with an interpersonal model that evolved from Freud’s individual model, it has now moved to a system concept. Given its history, it is not surprizing that there is now a broad spectrum of approaches that fall under the family-systems heading. This spectrum has been divided into four schools (Foley, 1974). At one end is the “ego psychology” approach of object relations, which spends more time on past relationships. At the other end is the objective theory of strategic intervention, which more emphasizes current system functioning. Family systems and structural family therapy provide the stepping stones between the two extremes … family systems being closer to the object-relations approach, and structural family therapy being closer to the “here-and-now” approach of strategic intervention.
Object Relations
This approach is generally similar to traditional ego psychology, in particular with the theories of Ronald Fairbairn (Guntrip, 1971). The word “object” in this connection refers to “people.” There are differences between object-relations therapy and traditional ego psychology, however. Object-relation therapists, such as Melanie Klein and Ronald Fairbarn, hold that a satisfying object relationship is a fundamental need. This contrasts Freud’s view that gratification of instincts is the basic drive. Object-relations therapists spend time analyzing past relationships and discussing how they influence the present. The other family therapists tend to play down the conscious aspect of learning, believing that an emphasis on this cognitive process slows the rate of change.
Family Systems
This approach is sometimes called the Bowen system theory, after Murray Bowen. Family systems therapy attempts to teach people to respond to their system, instead of merely reacting. “Responding” entails making a choice on the basis of reason, although feelings and the needs of the family are taken into account. The goal is to help a person differentiate from one’s family system, while remaining in touch with the system.
Structural Family Therapy
Lyman Wynne (1961) originally introduced the concepts of “alignments and splits,” which Salvador Minuchin (1967, 1974) developed into this approach, which is most often associated with him. The structural therapist works on the boundaries between family subsystems in an effort to change the family structure (the alliances and splits). The structural therapist sees interlocking triangles forming among the parents and children, rather than among the grandparents, parents, and children. The goal of structural therapy has been defined as inducing a “more adequate family organization” to maximize growth potential in each of its members (Minuchin, 1974).
Strategic Intervention
This approach is farthest removed from the Freudian model. The original thinking about the formulation and resolution of problems, upon which strategic intervention theory was built, was done by Don Jackson. The main concepts are: (a) the symptom is the problem; (b) problems are caused by faulty life adjustments, especially at critical points like birth and death, (c) problems continue because attempted solutions only intensify them; and (d) the cure, paradoxically, is often accomplished by intensifying the problem (Weakland, et al., 1974). The goal of therapy in strategic intervention is to devise tactics that will force people to behave differently. The paradoxical technique of “prescribing the symptom” is often used.
Summary
The schools presented have the same basic concept of the family, and all agree that behavioral problems in the individual are the result of dysfunctional interaction in the family system. At the same time, each school has a special viewpoint that sets it apart from the others.
Object-relations and family systems believe in clarifying relationships from the past. Structuralists and strategic interventionists hew to the concept that if the present system can be changed, the past need not be an issue (equifinality).
Families being treated by object-relations and family-systems therapists will tend to be seen over a longer period than those by structural or strategic-intervention therapists. This is due to a difference in goals. In the first group, deep changes in interactional patterns will be the goals; in the latter, the problem is more symptom oriented and treatment time will be shorter.
Use of Techniques
Reenactment
Reenactment allows the therapist to see in session what happens in the family, rather than relying on reports. If two people are having difficulty talking to each other, the therapists might request that the two talk to each other in the session. If there has been a fight, the therapist might ask that the family replay the argument as it originally occurred.
Homework
Homework not only extends the actions learned in session to the real world, it also defines therapy as a place where solutions to problems are found, and not just where talking takes place. In addition, it reinforces the validity of behavior modification techniques in the minds of the family members.
Family Sculpting
Family sculpting allows the therapist to nonverbally examine the issues of closeness and power within the family.
Paradoxical Intervention
Paradoxical intervention makes use of therapeutic “judo”: using the strength of the dysfunction against itself. Haley (1976) has outlined the eight stages of paradoxical intervention: (1) the client-therapist relationship is developed, with the goal being to change the client’s behavior, (2) there is a clearly defined problem, (3) there is a clearly defined goal(s), (4) the therapist presents a plan, often with the reason for using it, (5) the current authority on the problem (spouse, parent, etc.) is dethroned by the therapist in a graceful manner, (6) the therapist, through the use of paradoxical intervention, encourages the same self-defeating behavior in which the family is current engaged, (7) the therapist monitors the response, while continuing to encourage the (usual) behavior — no “rebellious improvement” is allowed, (8) the therapist refuses credit for any improvement in the condition, and may even act nonplussed over the improvement. Haley (1963) states that the basic rule is “to encourage the symptom in such a way that the patient cannot continue to utilize it.” This can be done, for example, by making the cure worse than the symptom, such as by prescribing an increase in the frequency or intensity with which the symptom is to occur.
Behavior modification
Some family therapists use techniques adapted from behavior modification. It should be noted, however, that in general, family therapists conceptualize these procedures differently.
Positive interpretation
Positive interpretation ascribes positive labels to clients’ motives. This is done primarily because blaming, criticism, and negative terms tend to increase resistance, as patients struggle to shed the pejorative label. Such negative or depressive maneuvers can render the therapist impotent. Consequently, the therapist might, for example, relabel “hostile” behavior as “concerned interest” (Weakland, et al., 1974), or perhaps as a desire to “get the best care possible” for the identified patient. This approach has a paradoxical flavor, as the couple finds that its efforts to fight are redefined (Haley, 1963).
Summary
Family therapy encourages a person to be an individual while remaining in touch with others, starting in the most basic relationship in life: the family. A balance is struck between the self and the family because mental health requires a development of the self together with a meaningful relationship with others.
Family therapy takes into account the total effect of one person’s behavior on another, and how the imbalance of one member can greatly alter the behavior and functioning of the total family interaction. There has been a tremendous development in theories, techniques, and treatments that propose to counter dysfunctional behavior in a very different way than individual psychotherapy would.
Because family therapy introduces context into the therapeutic process, it is more attuned to clients’ needs than other approaches (Marmor, 1983). According to some, the result may well be that family therapy will soon displace individual psychotherapy, including child therapy (Mora, 1974). As with the sudden interest in ecology and ecological systems that swept the country in the 1960s, the “ecologically sound” family therapy approach is a phenomenon waiting to happen. The “environmentalists” of the future will be psychologists, trained in family systems therapy, who redefine the interaction between man and his surroundings. After all, for most of us, other humans are a major feature in our habitat.
Of all the approaches, I feel most comfortable with the object relations and family systems approaches. These approaches concern themselves with the way people feel towards one another as being very important aspects of individual and family growth. The other two approaches (structural and strategic intervention) use power and behavioral strategies as their primary modes of teaching. In terms of my own personal style, I have found the family therapies that utilize feelings along with behavioral strategies to be a much more comfortable fit with my style as a human being and a therapist.
I also want to comment on Mora’s belief that family therapy will in time replace individual therapy. I feel that family therapy is a tremendous tool in the treatment of many problems. But variegated as it is, it is only one tool. We must remain flexible and inventive in approaching the problems of the individual. I think individual therapy will continue to be necessary in some cases. Examples of this are people who need reparenting, or a person who is reluctant to talk about his extramarital affair in the context of the family. However, I believe that family therapy has been the most dramatic and effective treatment approach in mental health for many years.
Case Study
This is the case of Zak, age four, a Caucasian boy, his mother, Jane, age 27, and his father, Bob, age 35. They were referred to the clinic because Zak had been in a pre-school for one year, and had refused to talk to anyone during that period of time. When his mother would pick him up at school, he would say, in a very low voice, “Hi.” This was the only word the school ever heard Zak say during his enrollment. The school had tried many ways of getting Zak to speak, but had been unsuccessful. Both the mother and father reported that Zak speaks to them at home very openly. However, they indicated he will not speak to relatives or to new people he meets. The mother presented herself as an anxious, worried woman who was overly close to Zak, and who had difficulty separating from him. The father had a limited and passive role in the raising of Zak. Zak was diagnosed as having an elective mutism disorder by the JASC. DSM III describes this disorder as having the following characteristics:
- refusal to talk in all situations outside of the immediate family, including school
- has the ability to use and comprehend speech and language
- has no physical disorder
I will describe three excerpts that were part of the nine month treatment in changing the family pattern that were perpetuating this disorder. The clinical characteristics that I will demonstrate in my learning are:
- family therapy techniques
- behavior techniques
- clinical process
- clinical self-awareness
- counter transference
Prior to the first excerpt, we had five sessions during which we established a relationship with this family, helping the family become more trusting of the therapeutic team. Up to this point we had not confronted the problem of the mother’s separation issue with Zak, or the father’s passive role in the family.
Case Excerpt 1
The mother continued to explain all of Zak’s non-verbal behavior. I asked her if she noticed that she seemed to anticipate every look and gesture her son made and then explain it to us. The mother said, “That’s because Zak won’t say anything.” Dr. Fleming said in a light but firm way, “Boy, it would be nice to have someone like you around.” Turning to the child, he said, “You’re not ever going to need to talk if mom keeps talking for you.” Zak looked at his mother with a surprized reaction.
I told Zak that we were going to make a new rule in these sessions: from that point on, mom could not answer for him. He looked at his mother in a mildly upset manner. I said to him, “You don’t look as if you like my rule.” The mother also appeared a little uncomfortable at what I was requesting of her. I said to the mother in a firm and empathetic way, “I can see this is hard on you, but Zak needs to find out he is a big boy and does not need help from his mom all of the time.”
Summary for Excerpt 1
I started feeling irritated with the mother’s continuing interpretations of Zak’s non-verbal behavior, even though I did not show in my tone or attitude I was feeling this way. These feelings made me examine my counter-transference feelings. I realized my mother always explained everyone’s behavior, and was excessive in dominating conversations. In some ways this mother reminded me of my mother. I also recognized another part of this irritation centered with the father because of my feelings with his lack of assertiveness with the family. I think I always had wanted my father to be more assertive with my mother, because I felt unprotected by my father. If I had allowed these feelings to get in the way, I either could have been inappropriate in my response to the mother, or tried to compete with the mother to protect the child.
I showed my clinical self-awareness with my observation of Dr. Fleming’s paradoxical strategy with the mother.
I demonstrated my ability to confront this mother in a supportive and empathetic manner in pointing out to her that Zak needed to grow up, and did not need her help all the time. This also demonstrated my clinical self-awareness of the separation issue. Zak was going to have to separate before he could form his own identity within — yet apart from — the family.
By confronting the mother about not talking for Zak, I demonstrated my awareness of the importance of the separation issue between Zak and his mother.
Case Excerpt 2
In this excerpt I will demonstrate how we began to alter the family systems, affect the separation issue, and encourage the father to develop a more active role with his child.
Zak came into the session and sat next to his mother as he had in previous sessions. The father sat in the chair opposite Zak and his wife. I asked, “Where does Zak sit at the dinner table?” Mom said, “Always next to me.” I said, “Dad, I think you should ask Zak to sit next to you.” I asked the mom how she felt about that and she said she thought it was a good idea. I said to Zak, “I think it would be a good idea now to practice sitting next to your dad.” Zak had a scowl on his face. I said to him, “You look like you don’t like this idea, but mommy and daddy are going to make the rules and you will learn how to follow them and have fun with dad, too.” I asked the dad to tell Zak that he wanted his son to come over and sit next to him, and I asked the mother to encourage Zak to do so. Zak refused to move. I told the dad to get up and get Zak and walk him over to the chair.
Zak seemed a little sad being separated from his mother. I asked the mother how she felt, and she said it was hard to watch Zak look unhappy. I turned to Zak and said, “Mommy’s got to learn not to worry, even if you get a little upset, because you’re going to be okay, and you can be just as happy with your daddy.” The dad said that he was pleased that Zak was sitting next to him, and that he had expected it to be more of a struggle.
Summary for Excerpt 2
In this excerpt, I was able to demonstrate my use of a combination of behavioral strategy and family strategy techniques to begin to re-align the family system. These techniques helped Zak separate from his mother, and begin to feel safe enough to develop an alliance with his father. At the same time, we began to form an alliance between the mother and the father. Then when I cued the mother to reinforce the father, Zak began to see his father’s importance as part of the family. This was the beginning of enhancing the father/son alliance. We made use of negative feedback to restore the equilibrium in the family by seating Zak next to his father. I also used clinical process when I supported the mother’s feelings, while still being firm in giving her the message of how she needed to separate from the child.
Case Excerpt 3
I had previously talked to the parents, so when they came into the session they were prepared to explain some new rules to Zak about his refusal to talk to Dr. Fleming and myself. They then told Zak that neither of them would get him a game or play with him unless he used words, and that he would sit away from both of his parents until he verbalized what he wanted. If he did not say what he wanted within ten minutes, he would have to go sit in the corner facing the wall, and he would stay there until he spoke. Zak looked very surprised. He sat in the chair and refused to talk. You could see at this time he was visibly upset, and he kept looking to his mother for cueing. By this time his mother had been taught to turn away. After ten minutes, the father said, “I guess we’ll have to put Zak in the corner.” Zak still refused to talk, so the father led him to the chair.
Zak sat in the corner for about thirty minutes, during which time we played one of his favorite games. The strategy was to make him feel that, by not talking, he was losing something else that was very important to him. Zak was starting to cry, but he finally whispered that he wanted to get up. The parents turned to him and were very happy. I said to him empathetically, “I always knew you could talk in front of people. And I think mom and dad now know that you can learn to talk more and more when other people are around. I’m very proud of you; I know how hard that was.” I turned to the parents, “I think Zak needs some homework.” The parents turned to Zak and said, “We’re very proud of you, but from now on you are going to learn to use words a little at a time, and if you don’t there will be rules and consequences like you had today in this session. But we really know you can do it.”
Summary for Excerpt 3
This excerpt demonstrated how I was able to educate these parents in communicating in a different way, making their expectations clear with their child using behavioral strategies, family alliances, and establishing expectations for him. Seating Zak in the corner was an example of a strategic intervention that I used to change his behavior pattern. I also demonstrated my ability to help Zak confront his omnipotent behavior and learn to listen to the expectations of his parents and talk in front of people other than his family.
Concluding Remarks
In these excerpts, I helped this couple see that this was a family problem, by showing them how they perpetuated their son’s refusal to talk. First, I helped the mother see her part in sabotaging her husband’s relationship with their son. Second, I was able to help the mother see that the boundaries with her son were inappropriate in that she was enmeshed with his feelings.
I used a combination of behavioral and family strategies to help change the child’s symptomatic behavior. By facing the child toward the wall, I prevented the child from having any visual contact with his mother, because even visually she could cue the child that she was worried about him and felt badly for him.
The therapeutic team’s major alliance was with the father, because the imbalance in the family system was the child’s overattachment with the mother.
Dr. Fleming’s point about Zak not having to talk while his mom was available was an example of a paradoxical technique we used to help Zak’s mother see the irony of her behavior.
I used clinical process and a paradoxical sense to help the mother and father see the irony in their behavior. Other clinical processes that were used with this family were support and empathy (to establish rapport with them).
In spite of the demands I was making, I was able to relate to this child in an effective manner, without hurting the therapeutic relationship, by being very supportive and accepting of him while he was struggling at giving up control of his words.
The clinical characteristics demonstrated in these excerpts were family therapy techniques, behavioral techniques, counter-transference, and clinical process.
Summary
I would like to comment on our use of the network approach in this case. In this type of problem, using a network approach is critical to fulfill improvements of this disorder. It takes into consideration all of the major systems that are part of the child’s life; the family system, the extended family system (including relatives), and the pre-school system. The network approach uses a psychotherapeutic intervention that focuses on changing the social environment of the individual family or larger group in distress. The social network mediates between the individual or family and society interaction with this complex reticulum of ties contributing to the development of one’s sense of psychological self (Wellman, 1980).
In this case, with Dr. Fleming’s consultation, I visited the pre-school, and consulted with them to reinforce the behavioral strategies we were teaching the parents. These strategies included:
- Zak was not allowed to play with his favorite activities unless he verbally requested them.
- Zak was also not allowed to be just around the adults in school.
- We increased the number of times Zak could not play with his favorite activities if he would not use speech.
- We helped the teachers see how they were perpetuating the problem by talking for Zak.
After three months of these interventions, Zak slowly began to use words in front of the staff. We also invited all significant relatives to come in to a session and we strategized how they should relate to Zak from that point on. The use of this approach, in my opinion, expands my understanding of how one must intervene in certain types of psychological dysfunctions. I found it extremely helpful to use the network approach to solve a problem of this nature.
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