Family Systems Theory and Therapy
Contemporary Family Therapy Developments
Functional Family Therapy (FFT)
Overview
Developed by James Alexander and Bruce Parsons.
Integrates behavioral and systemic approaches.
Focuses on the purpose (or function) of family member behavior.
Family member behaviors create and define interpersonal relationships, generate and maintain intimacy, and contribute to meaningful life experiences.
Has an evidence base, particularly in treating adolescents with disruptive behavior problems, violence, drug abuse, and other criminal behaviors.
Role of the Counselor
Make the specific functional qualities of family member behaviors explicit.
Operate on the premise that family member behavior is purposeful.
Help family members change risky and damaging behavior while addressing the behavior’s original intent through healthier means.
Strength-based approach: inherent strength and a natural ability to be resilient, doing their best in context.
Use a style similar to a curious researcher, asking questions and exploring client symptoms and family member reactions to behavioral improvements and escalation.
Seeks to understand the interpersonal payoff of the behavior of concern.
Key Questions for the Counselor
Is this the son’s way of maintaining a connection with Dad, albeit a tumultuous one?
Do Mom and Dad use the son’s behavior to maintain their roles as disciplinarian and consoler? Or to ignore their marital troubles?
Is there an element of attention-seeking that contributes to the son’s behavioral motivations?
Key Concepts and Change Strategies
All behavior is purposeful and serves to create either distance or intimacy in family relationships (Sexton, 2011).
Help families understand their behaviors in these terms, rather than labeling behavior as good or bad.
Systemic concept of circular causality is central.
Encourage the family to see the problem beyond the identified patient and consider the IP’s behavior to be serving a family purpose.
Encourage the family to recognize everyone’s contribution to problem maintenance.
Help families fulfill the behavioral purpose in less risky and more relationally responsive ways.
Relabeling is used to explain family member’s behavior in a compassionate way, revealing positive underlying behavioral motives.
Relabeling helps family members restructure cognitions around the problem and can lead to softer affective responses that are more sensitive to each family member’s interpersonal needs.
After understanding is reached, and more empathy is fostered among family members to eliminate blaming, therapists help the family change their behaviors using behavioral interventions.
The ultimate aim of these interventions is to help the family remain true to the initial intent of their behaviors, but find other means to achieve the same function.
Example of Relabeling:
Jill’s drug use brings mom and dad closer together.
Relabeling: "Maybe part of what Jill’s drug use is doing is bringing mom and dad closer together. Jill, you’re making quite the sacrifice to help your parent’s marriage."
Behavioral Interventions Example:
Instead of deescalating parental conflict and bringing her parents together through drug use, the three of them could find a common recreational pursuit (e.g., a community art class, music lessons, fishing, four-wheeling, etc.).
It also might be a relief to Jill if her parents agreed to go to couple counseling.
Multidimensional Family Therapy (MDFT)
Overview
Focuses on individual, family, and environmental factors in an effort to remediate adolescent behavior problems.
Cases often include youth and/or parents with substantial alcohol and drug problems.
Focuses on youth and family strengths and natural motivations but also directly addresses problems occurring on multiple levels.
Problem Areas
Poor family communication.
Family relationship distress.
School truancy, suspension, or dropout.
School achievement challenges.
Legal issues that youth and their parents are facing.
Community disengagement.
Youth skill deficits.
Parenting skill deficits.
Key Figures and Theoretical Perspectives
Howard Liddle is the primary architect of MDFT.
Integration of diverse intellectual perspectives and empirical research.
Dimensions from Bronfenbrenner’s developmental model, systems theory, adolescent identity development, parenting effectiveness.
Has an exceptionally strong research base.
Role of the Counselor
Approach therapy from a practical perspective, focusing on initial distress, subtle signs of motivation, and client strengths.
Initial engagement with clients is crucial to successful outcomes.
Engagement focuses on:
the adolescent,
the parent,
the interactions between parent and adolescent,
the “extrafamilial” (e.g., school, probation services; Liddle, 1995, p. 39).
Hone in on parent and youth fears to understand their distress and enhance motivation.
Make themselves available to provide services in whatever setting makes practical sense.
Help youth and parents develop the skills they need to strengthen family relationships and succeed in school and community contexts.
Key Concepts and Change Strategies
Skills-based, goal-oriented treatment.
Youth and parents are coached and counseled to directly take on the problems in their lives.
Problems and events that precipitate treatment usually involve family relationship distress, school truancy or suspension, substance abuse, and negative peer relationships.
Typical MDFT Treatment Objectives
Reduce or eliminate delinquency, criminal behavior, and substance abuse.
Improve parent and child mental health.
Improve school functioning.
Improve family functioning.
Focusing on adolescent identity development and personal goals can be used to enhance motivation and help adolescents develop prosocial interests.
Treatment also often involves facilitating constructive communication between youth and parents.
Additional treatment strategies include parenting skills training, communication skills training, and developing personal skills for coping with mental health challenges and stressful life situations.
Multisystemic Therapy (MST)
Overview
A “comprehensive family and community-based treatment”.
Theoretical Foundations
Bronfenbrenner’s (1979) theory of social ecology.
Social validity or the orientation toward providing assessment and interventions in the client’s real-world settings.
The reciprocal nature of human interaction.
Assess multiple social factors that contribute to behavioral problems and then intervene at one or more systemic levels.
Role of the Counselor
Delivered via treatment teams.
Teams include from two to four master’s level therapists, a supervisor, and administrative support.
Treatment is brief (3 to 6 months) but intensive (60–100 hours of contact).
Meetings and interventions focus on problems and settings consistent with the youth and family’s social ecology.
Comprehensively strength-based.
Therapists are optimistic in their communication with clients and stakeholders throughout assessment and treatment.
Child, parent, family, peer, school, and community strengths are identified.
Strengths are then used to address issues that contribute to problem behaviors.
Example:
A family friend with a positive affective bond with the youth might be recruited to provide afterschool supervision (or mentoring or tutoring).
Specific intervention strategies are constructed to address what MST therapists define as the drivers of the problems.
Key Concepts and Change Strategies
Caregivers are the key to achieving and sustaining positive long-term outcomes with youth.
Practical focus on caregiver competencies.
Therapists advocate for caregivers to make sure they’re provided with social support from friends, family, and the community.
As caregiver skills progress, therapists guide treatment toward reducing factors contributing to the youth’s problems and increasing, among other issues, positive peer support.
Case Presentation: The Jackson Family
Background
Court-ordered counseling after Jake, their 17-year-old son, was arrested on drug charges.
Family consists of Jake’s mom, dad, 14-year-old sister Anna, 10-year-old brother Luke, and 8-year-old sister Sarah.
Mom and Dad both have a long history of methamphetamine use and production.
Two years prior, the children were placed in state custody while Mom served a three-year prison sentence.
Counselor's Approach
Acknowledges the family's struggle with the legal system.
Addresses communication patterns and structural issues that are impeding the family’s growth.
Brings the family into the moment.
The first problem to emerge was the family’s struggle with the legal system.
The counselor acknowledged this as a problem, while also bringing the family into the moment and addressing the communication patterns and structural issues that were impeding the family’s growth.
Problem List
Sarah’s rigid role to protect her mother.
Mom and Dad’s inflexible caretaker and disciplinarian roles.
The parentification and later role dismissal of Jake.
Dad and Anna’s resistance/fear of the counseling process.
The family’s covert rule not to talk about past hurts, current fears, and anger regarding their drug use history and the children’s removal from the home.
Mom and Dad’s marriage (with the focus on their children, more information is needed to assess the parents’ marriage).
Problem Formulation
The Jackson family has been engaging in dysfunctional relationship patterns.
Dysfunctional patterns: (a) not speaking directly to each other, (b) not disclosing authentic reactions to one another (especially where past hurts are concerned), and (c) triangulating outside systems like child protective services and legal authorities to foster family connectedness.
The Jackson family structure, although able to shift in times of crisis (e.g., Jake taking on a parenting role when his parents were unavailable), is also quite rigid.
Sarah is entrenched in her mother-placating role, Luke is intermittently irrelevant, Dad blames, and Mom placates.
The family isn’t a pleasant or supportive place for the members.
Creating experiences where the family can experiment with new, more authentic ways of being, including ways in which they might experience positive feelings and support from one another.
Interventions
Change doesn’t occur primarily through talk or insight. Change happens through action in the now.
Creates experiences responsive to the family’s moment-to-moment needs.
Witnesses Sarah placating Mom, the counselor intervenes by emphasizing the role and giving Sarah a toy shield to shift it into a playful (and overt) experience.
As Sarah relies on Mom for comfort, the counselor intervenes by asking Dad to move near Sarah to provide comfort, creating flexibility in his disciplinarian role.
The counselor empathizes with the family’s frustration about being in counseling and in the system.
Connecting and joining with their frustration and then prompts the family to uncover other sources of “unfairness” using a spontaneous experience to create a metaphorical pile of bullshit in the counseling session.
This experience freed the family to express frustrations about what was happening to the family as well as within the family.
Coached Sarah into temporarily letting go of her placating role and guided Jake toward congruent communication with his mom.
Outcomes Measurement
Many formal tests and rating scales for measuring family therapy efficacy or effectiveness exist.
Less formal assessments, such as reconstructing a genogram to look for evidence of change or repeated family sculpting can also be used.
Self-report and direct observations to determine counseling effectiveness.
Using self-report, counselors seek family member perspectives about family roles, rules, relationships, and satisfaction with family functioning.
Relying on observation, counselors use their knowledge and perceptions, evaluating families from an “outsider” perspective.
Assessment Tools
The Family Adaptability and Cohesion Evaluation Scale (FACES):
A commonly used self-report instrument for assessing family members’ satisfaction.
A 20-item scale has family members rate their current and ideal family situation in terms of flexibility and connectedness (Olson, 2000).
The closer the two scores are, the greater the satisfaction.
This assessment could be utilized as a pre- and post-intervention measure with the families like the Jackson family.
The McMaster Clinical Rating Scale (Epstein, Baldwin, & Bishop, 1983):
Another common family functioning assessment tool that evaluates six areas: (1) roles, (2) communication, (3) problem solving, (4) affective responsiveness, (5) affective involvement, and (6) behavioral control.
The Beavers Interactional Competence and Style (BICS).
The Circumplex Clinical Rating Scale (CCRS).
Considerations for Assessment Selection
Be aware that there are well over 1,000 couple and family assessments available (Goldenberg, Stanton, & Goldenberg, 2017).
When selecting an outcomes assessment, be sure to find one or more that share a similar lens to your theoretical orientation and are representative of what you intend to measure.
Evaluations and Applications
Evidence-Based Status
Research on family therapy is generally positive.
In an early review, Shadish and Baldwin (2002) reported on 20 meta-analyses of couple and family research.
Reported a combined (couple and family outcomes) overall effect size of compared to no treatment controls.
This is a moderately positive effect size; the efficacy of couple therapy was slightly better than family therapy.
Traditional Family Therapies
Compared to contemporary evidence-based family therapies, the traditional models (i.e., intergenerational, structural, strategic, and humanistic-experiential) have much less empirical research.
Very little controlled empirical research focusing on Bowen family systems therapy outcomes.
A recent Iranian study showed that eight 90-minute Bowen family therapy sessions were more effective than no treatment in reducing marital conflict (Yektatalab, Oskouee, & Sodani, 2017).
Research on Structural Therapy
Has generated a few positive outcomes over the years.
Specifically, it may be effective for substance abuse, psychosomatic disorders, and conduct disorders.
The reviewers reported that structural family therapy improved well-being in HIV seropositive women and generally supported the utility of the structural approach.
Research on Humanistic and Strategic Family Therapy
Is even sparser and more equivocal.
There is no evidence of these approaches producing positive outcomes.
Integrating experiential activities into family therapy was reported to improve adherence and family engagement.
Multidimensional Family Therapy
Has substantial research support.
Efficacy for reducing substance abuse and related problems, improving school performance, reducing symptoms of co-occurring mental disorders, decreasing delinquent behaviors and delinquent peer socializing, reducing out-of-home placements, and reducing high-risk sexual behaviors.
Multisystemic Therapy
Has significant research support.
“Outcome research has yielded almost uniformly favorable results for youths and families”.
Treatment fidelity was noted to be important to treatment efficacy/effectiveness.
Functional Family Therapy
Had been empirically evaluated across more than 300 clinical settings.
A meta-analysis of 14 studies showed FFT as clearly superior to untreated control groups and slightly superior to other established treatments (e.g., cognitive behavior therapy).
Most of the research has focused on various delinquent behaviors among adolescents.
FFT’s effects were not significantly different than treatment as usually conducted in mental health settings (Hartnett, Carr, Hamilton, & O’Reilly, 2017).
APA Division 12 Findings
Family therapy as efficacious or probably efficacious for four different treatment populations.
Family-based treatment for anorexia nervosa.
Family-based treatment for bulimia nervosa.
Family-focused therapy for bipolar disorder.
Family psychoeducation for schizophrenia.
Family therapy also appears promising for assisting families who have children with health problems such as childhood obesity and asthma and adolescent suicide ideation.
Cultural Sensitivity
The cultural sensitivity of family therapy varies considerably across the different theoretical models reviewed in this chapter.
Bowen’s intergenerational approach, with its focus on individuation and pathologizing of emotional cutoff and enmeshment, has the potential to be insensitive to diversity issues.
It’s difficult to think of which cultural group, including members of the dominant culture, that Haley’s strategic approach wouldn’t potentially offend.
Minuchin’s structural family therapy was used respectfully with minority populations in and around Philadelphia.
The cultural sensitivity of structural family therapy was affirmed.
The evidence-based multisystems models have great potential for cultural sensitivity.
Levels Addressed in Multisystems Approach
Level I: Individual.
Level II: Subsystems.
Level III: Family household.
Level IV: Extended family.
Level V: Nonblood kin and friends.
Level VI: Churches, schools, and community resources.
Level VII: Social service agencies and outside systems.
Level VIII: Work.
Level IX: External societal forces (e.g., poverty, racism, discrimination, sexism)
Gender and Sexuality
Increasing consciousness partly inspired by feminist psychology and counseling, most family therapy approaches no longer explicitly blame mothers for their children’s psychopathology.
Family therapies may orient too specifically to traditional family structures and roles.
Functional family therapy has been critiqued for promoting traditional family roles.
Only 45.6% of couple and family therapy faculty members reported having received training in LGBTQ affirmative therapies.
LGBTQ sensitivity in family therapy training and practice has increased.
Spirituality
Religion and spirituality in family systems theory and family therapy was mostly absent until the 1990s.
Students would prefer more training in how to integrate religious/ spiritual issues into family work.
Variety of books, book chapters, and articles that focus on spirituality and religion in family therapy have been published over the past decade.
At this point in time, using strength-based and collaborative models is the trend in family therapy.
Concluding Comments
This chapter underlines the notion that no one exists in isolation.
Treatment at the systemic level must address these complexities and also engage families in ways that facilitate change.
The driving conceptual forces in family counseling (homeostasis, rules and roles, the notion of the identified patient, boundaries, alliances, coalitions, and triangles) remain consistent over time and approach.
Common factors in family therapy are what appear to garner the most research support.
This involves facilitation of counseling relationships where an alliance with the family sets a foundation for accessing familial resources and generating hope, which, in turn, stimulates risk-taking, new learning, and positive change in families.