About Family Theory

Family theories can be as stressful as families themselves, however, theory can serve as a reference point to assist the health provider. Although a dysfunctional family can be detrimental to a person’s well-being, having a family as an ally can be a valuable component for helping the patient. A family does not have to be perfect but if the good outweighs the bad, a PMHNP should use that to his or her advantage.

The hassle of managing a psychiatric patient can be tough work, let alone trying to fix a family. Therefore, this is a basic overview of family theories and information. Just to be clear, if you have a family that’s willing to work with you then therapy may be helpful, but if not -then it can be litigious and I would limit my interactions and keep it simple with the usual standards.

Family therapy is usually employed by a therapist. Therefore, this page is a formal understanding and hopefully one day, PMHNP’s will be able to provide therapy more often. In the meantime, psych NP’s can at least offer an abbreviated form of assistance with client families’.

• Functional Family: Defined as a family wherein a balance between these functions is achieved. Imbalances may result from over or under-emphasis of these functions.
• Dysfunctional Family: Defined as a family with a chronic inability to respond to the needs or to cope with changes and stresses in the environment.

5 Basic Family Functions 

• Provide support to each other
• Establish autonomy and independence for each person in the system
• Create rules that govern the conduct of the family and its members
• Adapt to changes in the environment
• Communicate with each other

The Purpose of a Functional Family or Therapy

• Help with symptom management: the parents or loved ones may be responsible for administering medications and for the patient to attend appointments.
• To have partners in helping with the care: when a family is advocating on your behalf, it decreases the tension and resistance to treatment.
• A functional family decreases the stigma of mental illness: the client may be from a different cultural background or generation in which any illness is viewed as a “weakness” and make people less likely to engage with treatment. Including the family in the plan of care, can help everyone get on the same page and improve outcomes.

Family Therapy Bases

Theoretical Perspectives on Families

• Functionalism: Meet the need to socialize children and reproduce new members.
• Conflict Theory: Reinforce and support power relations in society.
• Feminist Theory: Reflect gender hierarchies in society.
• Symbolic Interaction: Emerge so people can meet basic needs and develop relationships.

Establishing Goals 

• Facilitate positive changes in the family.
• Fostering open communication of thoughts and feelings.
• Promoting optimal functioning in interdependent roles.

Background of Family Therapy 

• Traditional therapies are oriented primarily to the past: Psychoanalysis, psychodynamic, interpersonal
• In the ’60s central focus became the present or “here and now”: Behavioral, gestalt, ego psychology, and family therapies.
• Concurrently and through the 80’s a movement from explanations, problems, and pathology towards solutions, competence, and capabilities—a future orientation.

Family Theories

Problem-Solving Therapy: guide interventions within the theoretical model. Developed out of a trend toward providing psychotherapy by teaching clients psychosocial skills (D’Zurilla & Goldfried, 1971)

• Formulate a problem as the focus of treatment
• Include a hypothetical explanation of the origin of the problem and what sustains it over time
• Formulate treatment goals derived from the problem formation
• Involves teaching a client how to use a step-by-step process to solve life problems
• Involves appraising problems as challenges, thinking that the problems can be solved, and realizing that effective problem solving tends to require time and systematic effort

Rational Problem Solving Skills Include:  

1. Attempting to identify a problem when it occurs
2. Defining a problem
3. Attempting to understand the problem
4. Setting goals related to the problem
5. Generating alternative solutions
6. Evaluating and choosing the best alternatives
7. Implementing the chosen alternatives
8. Evaluating the efficacy of the outcome

Systems Theory: maintains that individuals can only be understood in the context in which they exist

• A system is organized to be greater than the sum of its parts—wholeness
• Relationships among elements create boundaries around the system
• Systems are organized hierarchically and composed of subsystems
• Living systems control or maintain a steady state of balance—homeostasis
• The person is not the problem—the family system is the problem

2 Family Systems Theories; Bowen & Minuchin

Bowen Family System Overview 

• Dr. Murray Bowen an analytically trained psychiatrist researched his theory at NIMH with families having a diagnosed member with schizophrenia. The hypothesis was psychosis is a symptom of a family problem more than a disease. Applied his observations to less disturbed and normal families and further developed his theory of family systems. First multigenerational research on families.
• The objective is to take the intuitiveness out of therapy

8 key Concepts 

1. Differentiation of Self
2. Triangles
3. Nuclear Family Emotional Process
4. Family Projection Process
5. Cutoff
6. Multigenerational Transmission Process
7. Sibling Position
8. Societal Emotional Process

The Therapist 

• Do not act as a problem solver
• Coach clients to understand process & structure
• Encourage expanding familial ties
• Asks questions
• Neutral parts of triangles (best if the therapist observes from partially outside the family).

Goals of Therapy: Behavior change-not insight, assessment, genograms, process questions, relationship experiments,de-triangulation, coaching, taking “I-positions”, & displacement stories:

• Displacement stories are usually implemented through the use of film or videotape, although storytelling and fantasized solutions have also been used. The function of a displacement story is to provide the family with an external stimulus (film, video, book or story) that relates to the emotional process and triangulation present in the family but allows them to be considered in a less defensive or reactive manner. Films, like “I Never Sang For My Father,” “Ordinary People,” or “Avalon” have all been used by Bowen therapists to highlight family interactions and consequences and to suggest resolutions of a more functional nature.

Salvadore Minuchin’s Structural Family Therapy Overview

• Focused on what maintains psychopathology than what causes it.
• Emphasis is on how, when, and to whom family members relate in order to understand and change the family structure.
• Theory applied to non-traditional inner-city families. Suitable for families with single parenthood, illness, acting-out members, drug addiction, crime, and violence.

Families are open systems that continually face demands for change:

• External (death of a family friend, loss of home)
• Internal (birth of a child, or child’s adolescence)

The focus is on family interactions to understand the structure/organization of the family. Symptoms rooted in the context of family transaction patterns. The symptom is a function of the health of the whole family. Symptoms/presenting problems are viewed as a by-product of structural failings. Structural changes must occur in a family before an individual’s symptoms can be reduced.

Invisible set of functional demands or rules that organize the way family members interact and relate to one another. Made up of subsystems, coalitions, and boundaries. Two major types of troubled family structures: Disengaged & Enmeshed

Structural Family Goals 

• Reduce symptoms of dysfunction
• Bring about structural change because it is assumed that faulty family structures have:
  1. Boundaries that are rigid or diffuse.
  2. Subsystems that have inappropriate tasks and functions.

The Therapist

• The therapist is active and directive.
• The therapeutic task is to help move the family from a dysfunctional stage to a new stage by changing structural rules.
• To challenge rigid transactional patterns.
• To free the members to grow and relate through healthy patterns.
• Actively engage the family unit to initiate structural change by joining and accommodating.

Contextual Theories by Haley & DeShazer

Overview of Strategic Therapy by Jay Haley: The patient’s symptoms are metaphorical and a result of attempts by family members to correct what they consider “problem” behavior.

• Symptoms reflect problems in the hierarchal structure
• Therapy focuses on short-term targeted efforts to solve a specific problem or symptom
• The Goal is to change sequences of interactions that maintain the problem
• Interventions are problem-focused and behavioral-oriented. Problem defining, problem-solving, reframing.

Techniques

• Straightforward directives -(tasks) designed with the expectation of family members’ compliance
• Paradoxical directives –a negative task assigned when family members are resistant to change; the task is noncompliance
• Reframing belief systems –relabeled behavior problems to more positive meaning (i.e. jealousy reframed as caring)

Solution-Focused Brief Therapy by Deshazer, O’Hanlon, & Berg: the focus is to rework solutions in the present situation that have previously worked. The goal is effective resolution using personal resources and strengths. Therapeutic conversations:

• Miracle questions
• Exception-finding questions
• Scaling questions

Basic Principles 

• It can be used in a variety of settings with a variety of problems.
• Therapy is collaborative and cooperative.
• Uses the resources available to the client.
• Clients define the goal.
• Goals are specific, behavioral, and obtainable.
• Problems are reframed in a more positive way.
• Change is constant-behave as if a change is inevitable.
• It looks at the positive side of problems and what works.

Solution Focused Therapy Basic Concepts

• Places emphases on the future rather than the present or past.
• All people are free to make choices.
• Clients are their own experts who know what is best for them.
• The therapist accepts the client’s view of reality & creates an expectation of change.

Techniques of SFT 

• The miracle questions: “If a miracle were to happen tonight while you were asleep and tomorrow you awoke to find the problem no longer existed, what would be different?” “How would you know the miracle took place?” “How would others know?”
• Exception finding questions: directing clients to a time in their life when the problem did not exist moves toward a solution by searching for any exceptions to the problem. “Was there a time when the problem did not occur?” “What was different about the times when things were working?”
• Scaling questions: “on a scale of 1-10 with 10 being very anxious or depressed how would you rate how you are feeling now?” Useful to highlight small increments of change.
• The Nightmare Question: “Think about having a terrible nightmare where your problem was amplified. What would be happening to let you know your nightmare came true?” This might be used when the client minimizes or denies his or her problem.
• Don’t ask a client to do something that he or she has not succeeded at before. Avoid analyzing the problem. Be efficient! Don’t look for problems or solutions that won’t work

Formula Tasks of SFT 

• Labeling: Externalize the problem so that the person is not the problem but the problem is the problem.
• Normalizing: Clients have complaints, issues, and concerns, -not symptoms, problems, or pathologies.
• Insight: Insight is not needed to solve the problem.
• Support and encourage the client’s success.
• Understand the client within his or her culture and worldview.
• Because the client is seen as an expert, it can work well for some clients of other cultures.
• Shift the conversation away from how things have stayed the same.
• Recognize the fact that problems may indeed be out of the client’s ability to change them because the problems are system bound however reactive behaviors can change and be empowering.

Basic Rules and Assumptions of SFT 

• “If it ain’t broke, don’t fix it”: The client determines the goals of counseling, not the therapist.
• “Once you know what works, do more of it”: This helps the client see positive behaviors and reinforces proactive behaviors.
• “If it’s broke, do something to fix it. If it doesn’t work, don’t do it again”: If it is not working there is no need to try it again.
• It is usually unnecessary to know a great deal about the complaint to resolve it.
• It is not necessary to know the cause or function of a complaint to resolve it.
• A change in one part of the system can affect change in another part of the system.
• Rapid change or resolution is possible.