Family therapy is a clinical approach to treating mental health and relationship problems based on the assumption that dysfunction can best be understood and treated by examining the social context in which it exists. Emerging as an identifiable ‘‘field’’ in the 1950s, family therapy was, and continues to be, characterized by attention to the interaction and communication patterns existing within couples and families. Several precursors set the stage for what, at the time, was thought to be a dramatic and controversial shift in clinical treatment from a focus on individuals to families.
First, the profession of social work emphasized the need to treat families as units. Recognizing that treatment of one family member would both impact and be impacted by other family members led to the practice of family casework in the early 1900s. Second, the early 1900s also saw the child guidance field begin in Europe and move to the United States. Psychiatrists working with children gradually came to acknowledge and write about the significance of the family in understanding the child. Nonetheless, this new orthopsychiatry movement continued to promote individual psychoanalytic treatment with children. Third, the 1920s and 1930s gave rise to the marriage counseling movement in the US. Made up largely of physicians, clergy, and social workers, this group began working with spouses together.
While writings and practice from the fields of social work, child guidance, and marriage counseling readied the larger mental health field for a paradigm shift, it was changes in psychiatry that are generally seen as the major impetus in the development of family therapy. Frustrated by the limited effectiveness of psychoanalysis for mental illness, particularly schizophrenia, and influenced by the writing emanating from social psychiatry, most notably the work of Harry Stack Sullivan, several individuals and teams began to study and develop new treatment modalities with families of schizophrenic patients. Although the treatment models developed throughout the late 1940s and 1950s varied on many dimensions, it was their similarities and their contrast to the prevailing psychoanalytic thought of the time that led ultimately to a unified field. The primary theme that ran throughout the models was the concept of wholeness; families were more than the sum of their members and the emergent relational and interactional components were the focus of the therapist’s intervention. Common characteristics of what came to be called ‘‘family systems’’ models of therapy included circular causation, function of symptoms, boundaries and organization, and communication patterns.
Multidirectional/circular causation is the notion that change in any part of the family impacts all other parts and that any given behavior cannot be understood linearly by what preceded or followed it. Instead, behavior must be considered by looking more broadly at the interactional field in which it is located.
Function/purpose of symptoms refers to the assumptions that symptoms exist for reasons in families. Although the purpose a symptom served may not be obvious to family members and be counter to stated family goals, early family therapy maintained that the symptom was currently or had been functional at some point in a family’s history. For example, while the young adult child who cannot successfully separate from parents and lead an independent life may seem like a problem to parents, the continuation of this behavior may serve to keep the parents united by their joint focus on a troubled child.
Boundaries and organization refer to structural characteristics of families. Organization addresses how the family has structured roles and relationships to meet its tasks or goals. Boundaries, on the other hand, address the degree of fluidity and adaptability in family organization. While boundaries need to be flexible enough to respond to changes in family needs and environmental demands, they should not be so malleable that family members and subsystems lose their sense of distinctiveness. For example, parents who allow children to become involved in their arguments, or share marital discontents with their children, would be said to have weak boundaries around the marital subsystem. Conversely, families who could not adapt and take on different tasks when a mother becomes ill, or families that could not respond effectively to age appropriate changes in children’s needs for guidance and affection, might be thought of as rigid in their boundaries and organization.
Communication patterns refer to the messages that family members send one another. The emphasis here is not simply on the words spoken but on both the multiple levels of messages sent and the metacommunications about how messages are to be interpreted in the context of this relationship. Thus, the statement, ‘‘tell me how you feel,’’ will be interpreted and responded to very differently in a family that has low tolerance for anger and dissension than in a family that respects differences of opinion.
Throughout the 1960s and 1970s family therapy increased in prominence in the mental health field as publications and training programs proliferated. However, the late 1970s and 1980s saw several critiques of the field. The field’s singular focus on the system and lack of attention to individual biology, psychology, and responsibility were criticized from two primary quarters. Families of the mentally ill challenged family therapy for blaming them for their children’s illnesses by focusing on the function of a symptom in the family and using language (such as ‘‘schizophrenic family’’ or ‘‘alcoholic family’’) that held the entire system accountable for a problem. Likewise, feminist scholars criticized the circular systemic thinking and language that held both victim and abuser responsible for the violence. Addition ally, feminists criticized the field for promoting traditional family structure and failing to incorporate the larger cultural system into therapists’ understanding of how gender and race impact family dynamics.
Both in response to these criticisms and as part of the movement toward integration in the mental health field in general, family therapy is continuing to evolve.
The last decade has seen a refocusing on the individual within the family system, and increased attention to issues of race/ethnicity, gender, and sexual orientation in treatment. Further, the strict division between models is eroding as integrative models emerge, and non-systemic postmodernist models – such as narrative and social constructionist models – grow in prominence in the field. An additional change is the integration of family therapy with other systems of service delivery, most notably family medicine.
The primary challenge currently facing family therapy is the challenge facing all mental health fields. The increased demand by insurers for evidence based treatment has led to an increase in research assessing the effectiveness of specific treatment protocols with specific populations.
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