FAMILY AND COUPLES THERAPY:POSSIBLE RISKS

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Clinical Psychology (PSY401)

Lecture 36

FAMILY AND COUPLES THERAPY

FAMILY THERAPY:

Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family.

It may be conducted by a pair of therapists--often a man and a woman--to treat gender-related issues or

serve as role models for family members. Although some types of family therapy are based on behavioral or

psychodynamic principles, the most widespread form is based on family systems theory, an approach that

regards the entire family as the unit of treatment, and emphasizes such factors as relationships and

communication patterns rather than traits or symptoms in individual members.

PURPOSE:

The purpose of family therapy is to identify and treat family problems that cause dysfunction. Therapy

focuses on improvement in specific areas of functioning for each member, including communication and

problem-solving skills.

Family therapy is often recommended when:

· A family member has schizophrenia or suffers from another severe psychosis; the goal in these

cases is to help other family members understand the disorder and adjust to the psychological

changes that may be occurring in the patient.

· Problems cross generational boundaries, such as when parents share a home with grandparents, or

children are being raised by grandparents.

· Families deviate from social norms (unmarried parents, gay couples rearing children, etc.). These

families may or may not have internal problems, but could be troubled by societal attitudes.

· Members come from mixed racial, cultural, or religious backgrounds.

· One member is being scapegoated, or their treatment in individual therapy is being undermined.

· The identified patient's problems seem inextricably tied to problems with other family members.

· A blended (i.e. step-) family is having adjustment difficulties.

PRECAUTIONS:

Before family therapy begins, family members are required to undergo a comprehensive clinical evaluation

(interview) that includes questions of a personal and sensitive nature. Honest communication between the

family members and the therapist is essential; people who are not willing to discuss and change behaviors

may not benefit from therapy.

Families that may not be considered suitable candidates for family therapy include those in which:

· One or both parents is psychotic or have been diagnosed with antisocial or paranoid personality

disorder.

· Cultural or religious values are opposed to, or suspicious of, psychotherapy.

· Some family members cannot participate in treatment sessions because of illness or other physical

limitations.

· Individuals have very rigid personality structures and might be at risk for an emotional or psychological

crisis.

· Members cannot or will not be able to meet regularly for treatment.

· The family is unstable or on the verge of break-up.

Intensive family therapy may be difficult for psychotic family members.

HISTORY OF FAMILY THERAPY:-

Family therapy is a relatively recent development in psychotherapy. It began shortly after World War II,

when doctors who were treating schizophrenic patients noticed that the patients' families communicated in

disturbed ways. The doctors also found that patients' symptoms rose or fell according to the level of tension

between their parents. These observations led to considering a family as an organism (or system) with its

own internal rules, patterns of functioning, and tendency to resist change. When the therapists began to treat

the families as whole units instead of focusing solely on the hospitalized member, they found that in many

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cases the schizophrenic family member improved. (This does not mean that schizophrenia is caused by

family problems, although they may aggravate its symptoms).

This approach was then applied to families with problems other than schizophrenia. Family therapy is

becoming an increasingly common form of treatment as changes in American society are reflected in family

structures; it is also helpful when a child or other family member develops a serious physical illness.

Family therapy tends to be short term, usually several months in length, aimed at resolving specific

problems such as eating disorders, difficulties with school, or adjustments to bereavement or geographical

relocation. It is not normally used for long-term or intensive restructuring of severely dysfunctional

families.

In therapy sessions, all members of the family and both therapists (if there is more than one) are present.

The therapists try to analyze communication and interaction between all members of the family; they do not

side with specific members, although they may make occasional comments to help members become more

conscious of patterns previously taken for granted. Therapists who work as a team also model new

behaviors through their interactions with each other.

Family therapy is based on systems theory, which sees the family as a living organism that is more than the

sum of its individual members and evaluates family members in terms of their position or role within the

system. Problems are treated by changing the way the system works rather than trying to "fix" a specific

member.

Family systems theory is based on several major concepts:

The identified patient:-The identified patient (IP) is the family member with the symptom that has brought

the family into treatment. The concept of the IP is used to keep the family from scapegoating the IP or using

him or her as a way of avoiding problems in the rest of the system.

Homeostasis:-This concept presumes that the family system seeks to maintain its customary organization

and functioning over time. It tends to resist change. The family therapist can use homeostasis to explain

why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and

what is likely to happen when the family begins to change.

The extended family field:-The extended family field is the nuclear family plus the network of grandparents

and other members of the extended family. This concept is used to explain the intergenerational

transmission of attitudes, problems, behaviors, and other issues.

Differentiation:-Differentiation refers to each family member's ability to maintain his or her own sense of

self while remaining emotionally connected to the family; this is the mark of a healthy family.

Triangular relationships:-Family systems theory maintains that emotional difficulties in families are

usually triangular--whenever any two persons have problems with each other, they will "triangle in" a third

member to stabilize their own relationship. These triangles usually interlock in a way that maintains

homeostasis. Common family triangles include a child and its parents; two children and one parent; a

parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.

POSSIBLE RISKS:

There are no major risks involved in receiving family therapy, especially if family members seek the

therapy with honesty, openness, and a willingness to change. Changes that result from the therapy may be

seen by some as "risks"--the possible unsettling of rigid personality defenses in individuals, or the

unsettling of couple relationships that had been fragile before the beginning of therapy, for example.

NORMAL RESULTS:

The goal of therapy is the identification and resolution of the problem that is causing the family's unhealthy

interactions. Results vary, but in good circumstances they include greater insight, increased differentiation

of individual family members, improved communication within the family, and loosening of previously

automatic behavior patterns.

VARIETIES OF FAMILY THERAPY:

Conjoint Family Therapy:

In conjoint family therapy, the entire-family is seen at the same time by one therapist. In some varieties of

this approach, the therapist plays a, rather passive, nondirective role. In other varieties, the therapist is an

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active force, directing the. Conversation, assigning tasks to various family members, imparting, direct

instruction regarding human relations, and, so on.

Satir (1967a, 1967b) regarded the family therapist as a resource person who observes the family process in

action and then becomes a model of communication to the family through clear, crisp communication.

Thus, Satir viewed the therapist as a--teacher, a resource person, and a communicator. Such a therapist

illustrates to family members how they can communicate better and thereby bring about more satisfying

relationships.

Concurrent Family Therapy:

In concurrent family therapy, one therapist sees all family members, but in individual sessions. The overall

goals are the same as those in conjoint therapy. In some instances, the therapist may conduct traditional

psychotherapy with the principal patient but also occasionally see other members of the family. As a matter

of fact, it is perhaps unfortunate that the last variation is not used more often as a part of traditional

psychotherapy. Because it is often the case that an individual patient's problems can be understood better

and dealt with better in collaboration with significant others in the patient's life. The use of such

arrangements should facilitate the therapeutic process.

Collaborative Family Therapy:

In collaborative family therapy, each family member sees a different therapist. The therapists then get

together to discuss their patients and the family as a whole. As we saw earlier, the use of this approach with

child patients was one of the factors that stimulated the early growth of family therapy. In a variation of this

general approach, co therapists are sometimes assigned to work with the same family. That is, two or more

therapists meet with the family unit.

Behavioral family therapy:

Behavioral family therapy becomes a process of inducing family members to dispense the appropriate rein-

forcements to one another for the desired behaviors. Indeed, some therapists (Stuart, 1969) even have

family members use tokens for this purpose. For example, a husband might earn four tokens if he does not

watch Sunday football on TV and instead takes his wife for a drive in the country. Of course, it must be

made clear in advance exactly what these tokens may be exchanged for later!

Given the recent developments in cognitive behavioral therapy, it is not surprising that this approach has

found its way into the family therapy enterprise. Similar to cognitive-behavioral therapy for the individual,

the family "version" involves teaching individual family members to self-monitor problematic behaviors

and patterns of thinking, to develop new skills (communication, problem resolution, negotiation, managing

conflict), and to challenge interpretations of family events and reframe these interpretation if necessary.

The Couples Therapy:

The focus of couples therapy is to identify the presence of dissatisfaction and distress in the relationship,

and to devise and implement a treatment plan. The objectives of treatment are to improve or alleviate the

symptoms and restore the relationship to a healthier level of functioning.

Couples therapy, also called marital therapy or marriage counseling, is designed to help intimate partners

improve their relationship Couples therapy is a form of psychological therapy used to treat relationship

distress for both individuals and couples.

Purpose:

The purpose of couples therapy is to restore a better level of functioning in couples who experience

relationship distress. The reasons for distress can include poor communication skills, incompatibility, or a

broad spectrum of psychological disorders that include domestic violence, alcoholism, depression, anxiety,

and schizophrenia. The focus of couples therapy is to identify the presence of dissatisfaction and distress in

the relationship, and to devise and implement a treatment plan with objectives designed to improve or

alleviate the presenting symptoms and restore the relationship to a better and healthier level of functioning.

Couples therapy can assist persons who are having complaints of intimacy, sexual, and communication

difficulties.

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Precautions:

Couples who seek treatment should consult for services from a mental health practitioner who specializes in

this area.

Patients should be advised that honesty, providing all necessary information, cooperation, keeping

appointments on time, and a sincere desire for change and improvement are all imperative to increase the

chance of successful outcome. Additionally, a willingness to work "towards" and "with" the process of

treatment is essential.

Description:

Couples therapy sessions differ according to the chosen model, or philosophy behind the therapy. There are

several models for treating couples with relationship difficulties. These commonly utilized strategies

include psychoanalytic couples therapy, object relations couple therapy, ego analytical couples therapy,

behavioral couples therapy, integrative behavioral couples therapy, and cognitive behavioral couples

therapy.

Psychoanalytical Couples Therapy:

Psychoanalytic therapy attempts to uncover unresolved childhood conflicts with parental figures and how

these behaviors are part of the current relationship problems. The psychoanalytic approach tends to develop

an understanding of interpersonal interactions (at present) in connection with early development. The

success in development of early stages dictates the future behavior of interpersonal relationships. The

essential core of this model deals with the process of separation and individuation (becoming a separate,

distinct self) from mother-child interactions during childhood. A critical part of this model is introjection.

The process of introjection includes introjects (infant processing versions) of the love object (mother). The

developmental process of introjection forms the basis an unconscious representation of others (objects) and

is vital for development of a separate and defined sense of self. The psychoanalytic approach analyzes

marital relations and mate selection as originating from parent-child relationship during developmental

stages of the child.

Object Relations Couple Therapy:

The object relations model creates an environment of neutrality and impartiality to understand the

distortions and intra-psychic (internalized) conflicts that each partner contributes to the relationship in the

form of dysfunctional behaviors. This model proposes that there is a complementary personality fit between

couples that is unconscious and fulfills certain needs. This model supports the thought that a "mothering

figure" is the central motivation for selection and attachment of a mate. Choosing a "mothering" figure

induces further repression (non-development) of portions of personality that were not well-developed

(referred to as "lost parts"). This repression causes relationship difficulties.

Ego Analytical Couples Therapy:

Ego analytical approaches utilize methods to foster the ability to communicate important feelings in the

couple's relationship. This model proposes that dysfunction originates from the patient's incapabilities to

recognize intolerance and invalidation of sensitivities and problems in a relationship. According to this

model, there are two major categories of problems. The first category of problems relates to dysfunction

brought into the relationship from early childhood trauma and experiences. The second involves the

patient's reaction to difficulties and a sense of un-entitlement (a personal feeling that one does not deserve

something). A patient's shame and guilt are major factors precipitating the thoughts of un-entitlement.

Behavioral Marital Therapy

Behavioral marital therapists tend to improve relationships between a couple by increasing positive

exchanges and decreasing the frequency of negative and punishing interactions. This model focuses on the

influence that environment has in creating and maintaining relationship behavior. Behavior exchange

between partners is flowing continuously and prior histories can affect relationship interactions. Behavior

therapy in general is based on the idea that when certain behaviors are rewarded, they are reinforced. The

amount of rewards (positive rein forcers) received in relation to the amount of aversive behavior is linked to

an individual's sense of relationship dissatisfaction.

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Clinical Psychology (PSY401)

Cognitive Behavioral Couples Therapy:

The cognitive approach therapist educates and increases awareness concerning perceptions, assumptions,

attributions or standards of interaction between the couple. The central theme for understanding marital

discourse using cognitive behavioral therapy is based on the behavioral marital therapy model. A couple's

emotional and behavioral dysfunctions are related to inappropriate information processing (possibly

"jumping to conclusions," for example) and negative cognitive appraisals. This models attempts to discover

the negative types of thinking that drive negative behaviors that cause relationship distress.

Follow Up In Couples Therapy:

Treatment usually takes several months or longer. Once the couple has developed adequate skills and has

displayed an improved level of functioning that is satisfactory to both, then treatment can be terminated. An

awareness of relapse prevention behaviors and relapsing behaviors is important. (Relapsing behaviors refer

to the return to the behaviors that the couple is trying to change or eliminate.) Patients are encouraged to

return to treatment if relapse symptoms appear. Follow-up visits and long-term psychological therapy can

be arranged between parties if this is mutually decided as necessary and beneficial.

Positive Results:

A normal progression of couple's therapy is relief from symptomatic behaviors that cause marital discourse,

distress, and difficulties. The couple is restored to healthier interactions and behaviors are adjusted to

produce a happier balance of mutually appropriate interactions. Patients who are sincere and reasonable

with a willingness to change tend to produce better outcomes. Patients usually develop skills and increased

awareness that promotes healthier relationship interactions.

Risk Factors:

The major risk of couples therapy is lack of improvement or return to dysfunctional behaviors. These tend

not to occur unless there is a breakdown in skills learned and developed during treatment, or a person is

resistant to long-term change.

Limitations:

There are no known abnormal results from couples therapy. At worst, patients do not get better because

they cannot break away from self-induced, self-defeating behaviors that precipitate marital dysfunction and

distress. The problems are not worsened if treatment is provided by a trained mental health practitioner in

this specialty.

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