Work With Families
Step Six of the Decision Tree
Chapter 14: Family Therapy
Two Models of Social Work With
Families
• Content on work with families is frequently placed
in second year curriculum as an optional
specialization in direct practice (MSW)
• When family is the method of choice (step six)
two different practice models exist.
• One model is focused on service delivery;
financial assistance and protective services. See
chapter 15.
• The other model is focused on family therapy. See
this chapter.
Criteria For
Choosing A Method of Therapy
• When therapy is the treatment decision, clinical
social workers may choose individual, family, or
group therapy.
• Each method of therapy requires specialized
knowledge.
• Each method has a different skill set and different
conceptualizations of the worker-client
relationship, how to formulate what is the matter,
and how to enact the therapeutic process.
Selecting Family Therapy
as the Method of Choice
• Family therapy is the method of choice when
families deal with the ordinary problems of family
life (family life cycle).
• It is the method of choice when families encounter
predictable and unpredictable life stressors
• It is the method of choice when improvement in
an individual family member will not occur or be
sustained without changes in family structure and
patterns of family interaction.
Differentiating Family Therapy
From Individual Therapy
• Individual therapy is based on linear causality;
family therapy is based on mutual causality.
• Prior to General Systems theory, the major focus
in the behavioral sciences was on individual
functioning as reflected in psychodynamic theory,
classical behaviorism, neo-behaviorism and
learning theory.
• The goal of intervention in linear models is to
restore normal functioning through interventions
that biological, cognitive or psychological.
Linear and Mutual Causality
• Linear causality holds that behavior is biologically
determined (genetics) or reactive e.g. determined
by early childhood experiences or on antecedent
(S-R) or consequent (reinforcement) events.
• Mutual causality holds that behavior is multiply
determined. Therefore the focus of functioning
shifts from the individual to the (family) system.
• Individual problems are redefined as flawed
familial structures and flawed patterns of family
interactions.
Point of Entry to Family Therapy
Who is The Client?
• Index Person: The point of entry to family therapy
is usually through an index person (IP) who has
been referred for help. Problem exploration
indicates that family therapy may be the treatment
of choice.
• Designated Help Seeker: Alternatively, point of
entry may occur when an adult (e.g. a designated
help seeker, usually the wife/mother) seeks help
for a member who has been identified by others in
the family as in need of help.
Declarative Knowledge
Family Therapy
• For purposes of this chapter, 4 theory-based
practice models have been chosen to illustrate
family therapy and to differentiate it from
individual therapy. These models are: (1) family
systems theory,(2) family life cycle theory, (3)
Bowen’s theory of differentiation, and (4) Haley
and Minuchin’s structural-strategic theory.
• As a method, family therapy is more complex than
individual therapy in that the clinician must focus
on the family as whole and on each individual
member in interaction with other family members.
Overview of Theory
General Systems Theory
• General systems theory focuses on the
transactional patterns between components of a
system and on the transactions between one
system and another.
• This theory accepts mutual causality e.g. that each
component of a system impacts another and the
system as a whole.
• Every model of family therapy adopts or shares
system concepts but is, in addition, conceptually
unique.
General Systems Theory
Premises
The major explanatory premises derived from
General Systems theory are:
(1) The whole is greater than the sum of its
parts
(2) A change in one part of the system will lead to
changes in other parts of the system
(3) Systems are dynamic not static; therefore
systems are in a constant state of flux
(4) Causality is complex
General Systems Theory
Premises-Continued
(5) Feedback is a method of controlling how systems
function by inserting performance results that
allow for correction & change.
(6) Systems must remain stable (homeostasis) and
change (adaptability).
(7) Adaptability is essential if a system is to avoid
the forces of entropy (decay & dissolution).
(8) Morphostasis refers to structural constancy
(9) Morphogenesis refers to change within stability
General Systems Theory
Premises-Continued
(10) Tension refers to the push to maintain the
status quo (equilibrium) and the pull to
change or adapt (disequilibrium).
Family systems theory is a subcategory of
General Systems theory.
General Systems Theory
Concepts
• General System theory (Bertanlaffy, 1968) is a
theory found in many disciplines.
• A living system is defined as a complex of
elements with interactions that are ordered
(nonrandom).
• System is a concept used to differentiate it from a
collection where the parts remain individually
unchanged whether isolated or together.
General System Concepts
Continued
• A boundary is an invisible demarcation that
separates one system from another. All
systems have boundaries that identify it as a
system.
• Negative Entropy is a concept that refers to
the decline of energy and decay of a system
associated with with a closed system and
impermeable boundaries.
Model One:
Family Systems Theory
• When applied to families, concepts borrowed from
General Systems theory are borrowed and refined.
• System is refined as supra-system, subsystem and
focal system. The family is the focal system. The
environment in which it operates is the suprasystem and its members, in various combinations,
constitute subsystems.
• Structure All families create a hierarchy of its
subsystems: parental subsystem, child subsystem.
Family Systems Theory
Concepts-Continued
• Function-All families create patterns of
interaction whereby they carry out the necessary
tasks of maintaining the integrity of the family
system in order to keep it functioning.
• Boundaries-All families create boundaries that
govern interactions within the family system and
between the family system and those outside it.
Boundaries may be semi-permeable, permeable,
or rigid.
Family Systems Theory
Concepts-Continued
• Equlibrium (Homeostasis) All families must
maintain equilibrium (stability) and adapt to
new input (change)
• Feedback (input/output): Family therapists
intervene to correct the course of the family
system. Negative feedback brings a
deviating family system back on course.
Positive feedback exaggerates the deviation
Model Two
Family Life Cycle
• This model combines concepts from General
Systems Theory and from Psychodynamic
Developmental Theory.
• This model holds that families seek therapy when
stage-specific family or individual tasks get
derailed; progress to the next stage is blocked.
• Derailment may be caused by predictable,
normative, individual and family developmental
stages or may be caused by unpredictable life
events.
Family Life Cycle
Stages
Carter and McGoldrick identify six family life
cycle stages:
(1) Launching the young adult
(2) The couple
(3) Families with children
(4) Families with adolescents
(5) Launching children and moving on
(6) Families in later life
Family Life Cycle Assessment
Stage One Derailments
• Stage one- the single young adult must
separate from her/his family of origin
without cutting off or fleeing.
• Derailment occurs when families don’t let
go of their adult children or the adult
children remain dependent or rebel
Family Life Cycle Assessment
Stage Two Derailments
• The task of this stage is to form a new
family system separate and distinct from the
couple’s families of origin.
• Derailment consists of enmeshment (failure
to separate from a family of origin) or
distancing (failure to stay connected).
• Couples may experience interpersonal
difficulties in intimacy and commitment.
Family Life Cycle Assessment
Stage Three Derailments
• On stage three, the new family is tasked with
becoming caretakers to the next generation
• Derailment at this stage involves couple, and
parenting issues. Maintaining appropriate
boundaries with both sets of grand parents may
become an issue.
• Couples must work out a division of labor, a
method of making decisions, and must balance
work with family obligations and leisure pursuits.
Family Life Cycle Assessment
Stage Four Derailments
• In stage four, families must establish
qualitatively different boundaries for
adolescents than for younger children.
• Derailment at this stage is related to
adolescent exploration, friendships,
substance use, sexual activity and school
• Parents may face a mid-life crisis
Family Life Cycle Assessment
Stage Five Derailments
• The primary task of stage five is to adapt to
the numerous exits and entries to the family
system.
• Derailment occurs when families hold on to
the last child or parents become depressed
at the empty nest.
• Derailment can occur when parents decide
to divorce or adult children return home.
Family Life Cycle Assessment
Stage Six Derailments
• The primary task of stage six is adjustment
to aging.
• Derailment consists of difficulties with
retirement, financial insecurity, declining
health and illness, dependence on one’s
adult children, the loss of a spouse or other
family members and friends.
Family Life Cycle Assessment
Predictable and Unpredictable Crises
• All individuals and all families go through
predictable, normative developmental crises.
• In addition, individuals and families experience
unpredictable crises e.g. job loss, illness,
accidental injury
• Disruption in a family life cycle stage can
interfere with individual development ; similarly
disruption in an individual’s life cycle stage can
interfere with a family’s life cycle development.
Family Life Cycle Therapy
Therapeutic Process
• Therapy is perceived as helping families get back
on the developmental life cycle track after being
stuck or derailed at a particular stage.
• The therapeutic goal is progress from one
developmental stage to another.
• Often a clinician works with a dyad (parent/child;
parent/adolescent) to help the dyad recognize
(insight) and solve the derailment.
Family Life Cycle Therapy
Therapeutic Process
• Usually the clinician does not work with the
family as a whole.
• It is assumed that work with one part of the
system will benefit the system as a whole
• Whether working with a dyad is more
aligned with individual therapy or family
therapy is controversial.
Model Three
Bowen’s Family Therapy
• Bowen’s model is a blend of General Systems
theory and Psychodynamic theory.
• According to Bowen, relationship patterns
established in one’s family of origin are predictive
of relationship patterns in one’s family of
formation.
• Like the family life cycle model, the therapeutic
process in this model involves a single individual
rather than the entire family e.g. a change in one
part of the system affects the system as a whole.
Bowen Model
Key Concepts
• Key concepts in this model are: inter-generational
emotional transmission, horizontal and vertical
stressors, and individuation.
• Individual emotional health is tied to an inter generational emotional field. Problems occur in
families when the adults fail to differentiate
themselves from their family of origin and
recreate flawed emotional transaction patterns in
their family of formation.
• The family is an operative emotional field that
exists from cradle to grave.
Bowen
Vertical and Horizontal Stressors
• Vertical stressors are emotional norms and rules
transmitted across generations. Examples are
family secrets, attitudes, taboos, labels, legacies,
myths, loaded issues.
• Horizontal stressors refer to predictable
(developmental crises) and unpredictable current
events (life threatening illness, divorce, etc).
• Families may experience stress and anxiety when
they experience vertical or horizontal stressors.
• Intersect: family dysfunction is most likely
greatest when vertical and horizontal stressors
intersect.
Bowen
Individual Symptoms
• Horizontal and vertical stressors impact family
emotional transactions and individual symptom
formation.
• Family dysfunction is viewed as a maladaptive
emotional response to stress.
• A three generational genogram is used to visually
depict emotional transmission across generations.
• Individual dysfunction reflects an active familial
emotional system in need of correction.
Bowen
Therapeutic Process
• The goal of therapy is to help individual young
adults emotionally differentiate themselves from
their family of origin so dysfunctional emotional
transactions do not get replicated in their family of
formation; separation and individuation.
• The therapeutic process often involves coaching
an individual young adult to engage his/her
parents in a new healthy way of relating.
• Another therapeutic process involves boundary
adjustment; separate but connected.
Model Four
Structural-Strategic Family Therapy
Premises
• According to this theory, a family is regarded as
dysfunctional when it responds to internal or
external demands in a way that reflects a flawed
family structure or a dysfunctional pattern of
interaction.
• An index person’s “symptom” is perceived as a
system-maintaining or system maintained device.
• Dysfunctional patterns result from stress and block
healthy ways of relating.
Structural-Strategic Family Therapy:
Concepts: Structure
• Structure: Hierarchy of family subsystems; all
members have roles (tasks and functions) in the
family.
• Ecomap: Pictorial depiction of the family in its
environment (suprasystem: family’s formal and
informal networks, neighborhood & community.
• 4 major subsystems within families: (1) spousal,
(2) parental, (3) sibling, (4) individual
Structural-Strategic Family Therapy
Concepts: Function
• Repeated transactions establish internal patterns
of how, when and to whom to relate.
• The family system is maintained by a limited
number of rules, implicit or explicit, the prescribe
the rights, duties, and range of appropriate
behaviors within the family.
• Patterns that are functional in one situation may
not be functional in another situation.
• Family’s develop preferred patterns of interaction
are are resistant to changing them.
Structural-Strategic Family Therapy
Assessment: Flawed Familial Structures
Flawed Structures:
(1) Parental-child structure: child is allocated
parental power in the family
(2) Parental-flux: pattern of paternal leaving
Father (or mother) is in and out of the family;
military service, job-related travel, incarceration
(3) Familial stress: family negotiates stress in one
subsystem through other sub systems e.g.
spousal difficulties are handled through child
symptom formation.
Structural-Strategic Family Therapy
Assessment-Continued
Flawed Structures
(4) Family system boundary: Boundaries are
too diffuse or too rigid.
Flawed Patterns of Interaction: Assess
(1) Family routines
(2) Flow of information across boundaries
(3) Functional performance : support, regulation,
nurturance, socialization
(4) Task performance: getting up, dinner time,
chores etc.
Structural-Strategic Family Therapy
Assessment:
Rules:
Explicit rules:
“ Bedtime at 10:00 o’clock”
“Come home after school”
“No profanity in this house”
Implicit rules: Inferred from family Interaction
“Dad is always right”
“Don’t say what you really feel”
Structural Strategic Family Therapy
Therapeutic Process
• Joining: Therapist joins (use of self) entire family
in sessions; participant-observer in the family
process. Therapist accepts responsibility for
success/failure of his interventions.
• Probes: Identify dysfunctional structures;
Probes trigger family transactions that are
diagnostic.
• Directives: Therapist uses directives to trigger
family transactions that are either diagnostic or
corrective.
Structural-Strategic Family Therapy
Therapeutic Process
• Pain management: Therapist possesses skill to
contain and manage family & individual pain as
introduces stress needed for family to change.
• Unbalancing: Therapist aligns with one family
subsystem against another to correct flawed
structures.
• Boundary adjustment: Therapist uses space
(proximity/distance) to mark, create, strengthen or
weaken boundaries.
Structural-Strategic Family Therapy
Therapeutic Process
• Tasks: therapist assigns tasks to promote or
decrease communications & interactions among
members.
• Mapping: Is a diagnostic hypothesis of what is the
matter and its goal directed solution. It suggests
the technique to be used to achieve the desired
outcome.
• Blocking: Technique to restructure flawed
subsystem. Worker’s use of self to block faulty
transactions between family subsystems; the IP.
Structural-Strategic Family Therapy
Therapeutic Process
• Reframing: Worker strengthens subsystem
boundaries by labeling (reframing) the behavior of
the index person in positive terms.
• Paradoxical Interpretations: Therapist offers
explanation of behavior that is counter-intuitive
e.g. viewing symptomatic or problematic behavior
as healthy behavior used to benefit the family.
• Techniques of Structural-strategic family therapy
change how members order their interactions and
the purpose (function) of those interactions.
Critique of Family Therapy
• Cultural relevance: These models are criticized for
not being culturally relevant. Family structures
and norms governing family behavior vary across
cultures and within the same culture overtime.
• Bias: These models depend on some definition of
normal or functional. Critics charge that dominant
groups have the power to define and thus
categorize differences as pathology. Models do not
address gender discrimination or alternative
family structures.
Critique of Family Therapy
Continued
• Ideology: Definitions of family are ideologicallybased. Values determine the conceptualization of
family.
• Medical Model: Critics charge that these models
focus on deficits or symptoms rather than family
strengths.
• Status Quo : Family therapy is criticized for
maintaining the status quo (power differential)
instead of challenging discriminatory norms or
practice that negatively affect families or harm
individual members
Critique of Family Therapy
Continued
• Romanticized Version: Critics charge that family
therapy holds a romanticized and ideological
version of “the family”. The concept of “family”
often masks violence (psychological and physical)
toward women and children while it protects men.
• External Realities: Critics charge that these
models do not address the objective reality of
racism, discrimination, oppression and poverty
faced by many families.
Teaching Tools
• See exhibit 14.1 for an example of a family
therapy process recording.
• See exhibit 14.2 for a decision schema to guide
you in the use of selecting family therapy as a
method and in selecting an appropriate theorybased model of family therapy.
• See chapter 15 for working with families in need
of service delivery: financial assistance and /or
protective services.