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.