FAMILY AND MARITAL THERAPY
Family Therapy is a way of understanding the patient’s
symptoms by putting them in the context of their marital or family
relationships. Generally, the use of such a systemic framework is helpful for arriving
at a comprehensive diagnostic formulation and it thereby affects the overall
management plan. It is also a treatment modality. It can be used in isolation
or, more commonly, in conjunctions with other treatment approaches (organic,
psychodynamic and behavioural treatments). Research has shown that Family and
Marital therapy are particularly indicated in the majority of common child
psychiatric disorders. It is particularly useful in patients presenting with
child abuse, anorexia nervosa, depression, schizophrenia and marital and family
distress.
Family Therapy and Psychosis –
He studied family dyad and triad when a parent and child
form a relationship to the exclusion of the other parent. This involves the blurring of age, sex and
role boundaries. He suggested that such relationship is precursor in the
development of schizophrenia. He described two schizogenic family patterns:
"marital schism": The
family is in a constant state of disequilibrium through repeated threats of
parental separation. Communication consists of defiant and coercive attempts to
avoid and mask conflicts. Parents disqualify each other, seek collusions with
children thereby excluding the partner.
"marital skew": family
equilibrium is achieved through distorted parental relationship. The marriage
is not under threat, due to one excessively powerful and dominant parent.
Wynne studied whole families. He described certain family
communication patterns, which are styles of relating leading to perceptual and
thought disorders. Such styles have shared manoeuvres that serve to deny or
reinterpret the reality of feelings.
There is a lack of family complementarity within
dysfunctional family structure. The disjointed or fragmented communication
leads to disrupted interactions. A pressure is put on the child to maintain the
facade to avoid recognition of the meaningless of family relationships.
Basteson described the Double-bind relationship:
it is a context of habitual communication with impasses imposed on one person
by others in their relationship system.
It is a communication sequence whereby the different levels
of communication are contradictory. Repeated sequences create a special type of
learning context of conflicting injunctions from which the recipient cannot
escape and therefore cannot comment on the messages being expressed. The impact
of the contradictory communication sequences lead to a breakdown in the
individual's capacity to discriminate between the different levels of
communication provoking behaviour characteristics of schizophrenia.
1 .KEY CONCEPTS
Family structure:
It is the invisible set of functional demands that
organizes the ways in which family members interact. It operates through
transactional patterns.
Transactional patterns:
The repeated transactions establish patterns of how, when
and to whom to relate.
Boundaries:
These are the rules which define who participates and how
and when. It also determines sub-systems and thus the shape and characteristic
pattern of each unique family structure. It represents a continuum from diffuse
(‘enmeshment’) to rigid (‘disengagement’) boundaries.
Sub-system:
Generation, sex, interest or functions give rise to
Subsystems (spouse, parent ('executive'), sibling, grandparents etc.). Each
individual belongs to different subsystems, with different levels of power and
skills.
Dysfunction:
A deviation from the model of 'healthy' or 'normal'
(hierarchically organized) family, mostly when the following is present:
a)
Rigid, impermeable, diffuse or unclear boundaries
b) Coalitions
formed against third party
c) Coalitions
cross generational boundaries
d) Denied or
concealed coalition
Adaptation:
The developmental changes of family members and subsystems
and external pressures require recalibration of boundaries. Failure to do so
results in dysfunction.
2. THERAPEUTIC
TECHNIQUES
The basic goal is to induce "more adequate family organisation
by restructuring the system, creating clear and flexible boundaries, so that
family members can carry out age appropriate life tasks. The aim is to change
structure believed to perpetuates the problem behaviour. Dysfunctional
transactions are blocked and new or unused repertoires of transactions are
mobilized.
Joining:
The self-conscious activity of therapist to accommodates to
family's language and styles of communication by forming a partnership. It is
non-judgmental and an ongoing process.
Focusing:
This is a deliberate activity of exploring small area in
depth.
Enactment:
The therapist request from the family to enact a
transaction in the session to study the family members' habitual interactions
(rules), to try to push transactions beyond usual thresholds, and to enable the
family to try out different transactional repertoires in 'therapeutic' environment.
Intensification:
It is 'putting the heat on", by increasing affective
component of a transaction, by repetition, prolonging length of transaction,
altering spatial arrangements, boundary making, blocking family 'pull,
disrupting a transaction pattern…etc.
Unbalancing:
It is a conscious attempt to form coalition with one member
against another, or supporting one member at the expense of another (aligning
with existing hierarchical arrangement), thereby disequilibrating family
organization)
MILAN SYSTEMIC FAMILY THERAPY
(Selvini Palazzoli, , Cirillo,
Sorrentino)
1. KEY CONCEPTS
A Neutrality:
The therapist does not side or "unbalance", assumes 'curious" stance, and the team helps him to do so, taking the concerned about, observer status.
Hypothesizing:
The therapist makes preliminary attempts to explain the
patient's symptoms in terms of the contexts within which they occur. These are
working guidelines for organizing the therapist 's work.
Circular questioning:
The feedback to the therapist's will influence and shape
the therapist 's next question, leading to a joint construction of a new
understanding of the situation ("co-constructing new realities").
There is a particular emphasis on questions designed to elicit differences,
since it is through the perception of difference that we construct new
information and that different perceptions of self and others become possible.
Positive Connotation:
Both the symptoms of the patient as well as the symptomatic
behaviours of the others (family) are positively connoted and thereby the
homeostatic tendency of the system is utilised.
Paradoxical Prescription:
The prescription of the symptom and “more of the same"
by the therapist, creates a "paradoxical effect".
2. THERAPEUTIC TECHNIQUES
The major tool of Milan and post-Milan systemic therapists
is the process of asking circular questions.
Questions are seen as a source of information, suggestion, validation,
introducing new perspectives, perturbation, and as an initiator of search process for patients.
Questions relate to the following areas:-
What is the symptom that the patient presents? What is it
there for? What function might it serve?
What is the context of the symptom, i.e. what is happening
when the symptom occurs?
Why now? Why this symptom? (the physical, psychological or social reasons for the
presence of the symptom)
When is the symptom
present? When did it start? When is it
worse, when better?
Who has the symptom/problem?
Who is around when the symptom happens? Who can make it better,
who makes it worse?
Who is affected by the symptom and in what way? How does
the symptom affect the family and how does the family (and others) affect the symptom?
Therapeutic interventions include education of families
about illness through relatives' group meetings, meetings with patient and family.
One of the areas of educating patients and family is the importance of long-term
maintenance medication.
Family-based management approach (Falloon)
1) Agreeing
on the exact nature of problem/goal
2) Brainstorming
and listing all possible solutions
3) Highlighting
advantages/ disadvantages of each proposed solution
4) Choosing the optimal
solution
5) Formulating
a detailed plan to implement the solution
Psycho-education (Leff)
Aim of therapy is to reduce the emotional intensity as well
as the intensity of too much physical proximity
1) Education
"Schizophrenia is illness, but family plays a very
important part in keeping the patient well"
4 short lectures to families (patients not included) on diagnosis, symptoms, causes, treatment and
prognosis of the illness.
Family burden is acknowledged
2) Relatives - group
Once a fortnight for 90 minutes, hospital-based.
a)
To provide a safe place to express fears and anxieties
b)
to reduce the sense of isolation by sharing similar situations
and problems
c)
to encourage the relatives to share their solutions
3) Family sessions
Once fortnightly for one hour for approx. 9 months at home
Phases:
l) Engagement (slow, perseverance)
2) Reaching agreement on the main concerns in the family
focus on management problems
(Using
structural and behavioural techniques and task assignments)
3) Focus on manageable tasks
4) Focus on strengths
5) Empathising with family and normalizing