Family Therapy Concepts and Methods 10th Edition Time Timeout

Psychiatry (Edgmont). 2009 January; 6(1): 32–37.

Published online 2009 Jan.

Family Therapy with a Depressed Adolescent

Paulette M. Gillig, Md, PhD, Serial Editor

Paulette M. Gillig, Professor of Psychiatry, Department of Psychiatry, Boonshoft Schoolhouse of Medicine, Wright State University, Dayton, Ohio;

Abstruse

Families tin can have a significant influence on a child's mental wellness. Family therapy is a treatment modality that can exist used alone or in combination with other treatment modalities. Family therapy strategies include psychodynamic, structural, strategic, and cognitive-behavioral schools. In this article the different schools are described and a case of a depressed teenager is used to illustrate how each blazon of family therapy is implemented.

Keywords: family therapy, boyhood, depression

Introduction

Family unit relationships tin positively or negatively impact child development. This influence also occurs in the reverse mode: families influence the overall health of the kid and the child influences the overall health of the family. This bidirectional influence is greater when the child has a psychiatric disorder.¹ When treating children, family interventions are commonly incorporated to a greater or bottom extent. In fact, child handling has been referred to equally de-facto family therapy.ⁱⁱ A psychiatrist or therapist doing family therapy utilizes the connection that exists betwixt child and family with the goal of improving the overall functioning of the family. When a family functions better, the child functions better.³

Family unit therapy is a course of psychotherapy that directly involves all family members in improver to the "identified patient"—and explicitly attends to the interactions amidst all family members. If the focus is on the fix of relationships in which the person is intertwined, family piece of work tin can exist washed regardless of who is initially involved.^iv Family unit therapy focuses on the relational and communication processes of families in order to work through clinical bug, even though the child may be the just family member with overt psychiatric symptoms.⁴ This is because although one family unit member may be the "symptom bearer," the whole family unit is in distress. Interventions in family therapy are geared toward the family every bit a unit with the perspective that some individual symptoms are products of relationship struggles within this unit. These private symptoms are viewed as arising from and being complicated by the family arrangement matrix.⁵ Family unit therapy is considered more of an orientation than a specific type of therapy.

Introduction to the Case: A 15-Year-Old Boy and His Family unit

J was a 15-year-sometime boy who first encountered mental wellness treatment after he admitted to his parents that he had thoughts of hurting himself. He had been defenseless smoking cigarettes in his room at abode by his stepfather and in the verbal altercation that followed J told his female parent and stepfather that he "didn't intendance anymore and wanted to dice." J's stepfather became very angry and threw him out of the firm for being disrespectful and untrustworthy. The mother and then became enraged at her married man and told her hubby that if he kicks out J, she is going, as well.

J admitted to feeling depressed for several months prior to this episode. He wanted to be an histrion and said that he did not meet the point of studying or going to schoolhouse. Although he did well academically in the ninth and 10th grade, his grades declined significantly in 11th course to the point that he was ineligible to participate in extracurricular activities like the drama gild. He admitted to having difficulty fitting in and was associating with the kids who skipped class and took drugs. J's depressive symptoms included sad mood, decreased motivation, decreased energy, decreased concentration, and sleep difficulty. After breaking up with his girlfriend, he cut himself superficially on his forearm with a razor and had fleeting thoughts of suicide.

The Influence of Family: The "Biopsychosocial Model"

The biopsychosocial model attempts to understand the whole person by elucidating the interactions between the biological, psychological, and social aspects of an individual. Using this model in relation to a child, the family environment would be the most important social cistron. It is easy to sympathise how this family environment substantially impacts a child.⁶ Normal child development is associated with the positive family processes of secure attachment relationships, constructive parenting practices, and emotionally nurturing environments. On the other hand, risk factors for childhood psychiatric disorders include the negative family unit processes of parental pathology, family and marital conflict, coercive parenting practices, and persistent negative affect.²

Research using twin and adoption studies has been conducted to investigate the affect of both genetic and family factors. One study found that adopted children with a high genetic take chances for schizophrenia were more sensitive to adverse rearing practices in their adoptive family than were adopted children with low genetic gamble.^half-dozen There was a clear association between the diagnosis of schizophrenia and disordered rearing in the children with high genetic adventure, which was not seen in the children with low genetic risk. The characteristics of family unit operation associated with matted rearing included a tendency to exist critical, to be constricted, and to accept boundary issues. The conclusion was that both genetic run a risk and rearing surround were interactive in promoting either the protection against or the emergence of schizophrenia in the adoptive kid.⁶ Another report looked at how family dysfunction affected recovery from a major depressive episode. Inpatients who viewed their family performance as being "healthy" were more likely to recover within 12 months then those who rated their family functioning equally "poor." Family dysfunction in this study was characterized by poor communication, poor problem solving, and criticalness.⁶

Although it may at kickoff seem intuitive that family processes that precipitate babyhood psychiatric disorders place all children in a family at equal take a chance, findings from the behavioral genetic literature make a convincing argument that this is not the example.⁷ Shared environmental influences, although the same for all children in a home, are experienced and interpreted differently by each kid, so that these events go different for each private child based on the child's own temperament. In addition, children'south private characteristics affect parenting beliefs. Even siblings, who are similar due to their genetic makeup, are different based on their individual temperaments.^seven Individual temperaments accept an impact on how children's parents relate to them, such that each child in a family unit may experience a different parenting mode.

J's family dynamics. J'south family consisted of his female parent, stepfather, eighteen-year-onetime older sister, and 11-yr-old sis. J'due south biological parents divorced when he was two years former and his female parent remarried when he was six. His mother reported that his biological male parent was abusive toward her, only non the children. She left him after an incident where he struck her while she was holding J when he was an baby, and she felt J'due south safe was being seriously threatened. J had little contact with his biological male parent since the divorce, but contacted him recently because he wanted to leave his current family and live with him in another state. To J'southward disappointment, his biological father's response was noncommittal.

J's mother reported symptoms of posttraumatic stress disorder (PTSD) from the abuse she suffered from J's biological father likewise as from a sexual attack in her adolescent years. She also experienced chronic headaches and fatigue, which sometimes limited her interest with her children. She revealed that her family of origin was unstructured and that she had "too much freedom," which she felt contributed to the sexual assault she suffered. She believed that she was allowed to "run wild" and became involved with booze at a young age. Of her children, she felt almost similar in temperament to J. She feared that without more parental supervision he could cease up like her and put himself in dangerous situations.

J ever had a distanced human relationship with his stepfather. J's stepfather was a retired police officer who highly valued lodge and discipline. He did not concur with J'southward long hairstyle or passion for acting. He forced J to cutting his hair and change his fashion of wearing apparel later he was caught smoking. J admitted that sometimes he feared him when his atmosphere ignited. The stepfather was generally suspicious of mental wellness providers and viewed psychiatric symptoms as an excuse or a weakness. This caused marital issues in relation to the mother'southward PTSD symptoms as well equally J's depressive symptoms.

J's older sister had bipolar disorder and although she had been stable for the last two years, she had a difficult fourth dimension for several years and was unable to nourish a regular school. J felt his older sis was non held to the same standard as he was because of her psychiatric affliction, and he felt this was unfair. J felt that the expectations for success were all the more than potent for him due to his sis's illness. His sister as well smoked cigarettes and, as far equally J could call up, had never been reprimanded for this beliefs. J's younger sister had no mental wellness diagnosis, but did accept exaggerated separation anxiety when she was a young child, some of which was still evident. She got forth well with her siblings, but spent well-nigh of her fourth dimension with her mother at the exclusion of peers. Several times a year she would complain of a stomachache until she was allowed to stay home from schoolhouse. This was more frequent following the altercation between J and his stepfather, which raised the stress level for everyone in the home.

Psychodynamic Family Therapy

Family therapy can be divided into several different schools of thought: psychodynamic, structural, strategic, and cognitive behavioral. Although the goals of each school are similar, the techniques and strategies each employs are unique. A combination of these approaches is used in gimmicky family therapy.

The psychodynamic approach to family unit therapy is based on psychoanalytic theory. From this viewpoint family psychopathology is based on the intrapsychic processes of individual members.^v These intrapsychic processes shape 1's interactions with others, most prominently in intense emotional relationships like those among family members. The collective processes of all members merge into the "family neurosis."

According to psychoanalytic theory, prominent intrapsychic processes take place in the unconscious. These include repression, projective identification, some aspects of unresolved grief, and transference. An of import concept that involves these processes is "psychic determinism." Psychic determinism refers to the idea that mental events exercise not occur at random and that every behavior has a cause or source embedded in the individual's history. Transference occurs when one'south feelings, thoughts, and wishes are projected on another person who has come to correspond a person from an individual's past. One feels nigh and treats the other person (the "object") equally though he or she were that important person from the by. In private psychoanalytic psychotherapy, transference occurs within the therapeutic relationship and refers to projections of the patient onto his or her psychiatrist. Past dissimilarity, when speaking of family transference, the accent is on intrafamily projections and not those projections focused on the psychiatrist or family therapist.⁵

The process of dynamic family unit therapy involves bringing unconscious conflicts betwixt family unit members into consciousness using techniques like interpretation. Change is facilitated by 'working through' the unconscious transference distortions of each family member. Through this procedure, parents go aware of how conflicts in the present family system are related to their unconscious attempts to master onetime conflicts arising from their family unit of origin.⁸

Treating J and his family using psychodynamic family therapy. When the psychodynamic family therapist viewed J'due south family through a psychodynamic lens, the conflict betwixt J and his stepfather was rooted in past relationships: The stepfather was predictably resistant to engaging in treatment based on his suspiciousness of the mental healthcare system, but with time and the nonjudgmental acceptance offered by the therapist, all members, including the stepfather, began to see treatment as a rubber environment.

Information technology is revealed that the stepfather besides was harshly disciplined past his own father and at times physically reprimanded for not being masculine enough. J's long hair and interest in interim threatened his stepfather because his stepfather was unconsciously projecting his own fears and memories of punishment onto his stepson.

The mother's disharmonize with J was also embedded in her by. Her over-identification with J could exist understood equally projective identification of herself as a struggling adolescent. She was unable to enforce limits on him due to her own unresolved conflict with her female parent for non providing this for her equally an adolescent. The mother'southward unconscious anger toward her parents for non stepping in and protecting her was likely being internalized into her somatic symptoms of headaches and fatigue. These concrete symptoms as well served the subconscious purpose of giving her a fashion out of difficult parenting decisions and leaving them up to the stepfather.

J's symptoms of low also served an unconscious purpose. J spent the majority of his determinative years with his female parent and his siblings. E'er since she had married his stepfather, J perceived that the stepfather took the attention and love of his mother away from him. This created an "oedipal" conflict where J felt unconscious aggression toward his stepfather. This unresolved conflict manifested itself through J'southward current psychiatric symptoms.

The psychodynamic family unit therapist used interpretation of selected fabric to increment the family's insight into how the past was continuing to affect the present. With this insight, as well as an expanded repertoire of emotional expression, the family unit could solve its present conflicts effectively without being weighed downwardly by the by.

Structural Family unit Therapy

The structural family unit therapist views symptoms that occur in a particular family fellow member, oft the identified patient, to exist directly linked to the organizational context of the family.⁹ Family construction can be defined as the organization of the family unit unit that dictates how family members relate and how various family functions are carried out.¹⁰ The family structure involves a set of functional demands that organize the fashion in which family unit members interact. This structure is invisible to the members themselves. It is the therapist'southward goal to understand this structure and ultimately to facilitate transformation of the structure equally a ways of solving bug.⁵

Of import elements of family structure include boundaries, hierarchies, alliances, and coalitions. The clarity of boundaries within a family is vitally of import to the overall functioning of the family unit and can range from disengaged to enmeshed. Members of a disengaged family have no contact with each other. An enmeshed family has too much contact with each other. Boundaries are most of import between generation levels or 'subsystems' inside a family unit. For family unit functions to be carried out effectively, parents and children must have contact with each other, simply not interfere with each other.⁵

The beginning job of a family therapist who is utilizing a structural orientation is to make up one's mind the family unit structure. This is achieved by careful ascertainment of how family unit members talk and interact within the consulting room in relation to the presenting problem.^four Therapy involves shifting the family unit structure, and this is accomplished through the re-creation of family unit dialogues and manipulating geographical arrangement during sessions and via behavioral assignments exterior of session. The re-cosmos of family dialogues occurs when the therapist directs a family fellow member to talk directly to another fellow member rather than to another person about the particular family member'south beliefs. This technique is valuable in that is forces families to enact transactional patterns rather than describe them. Another in session technique simply changes where item family members are sitting in the consulting room to physically correspond the idea of challenging existing family structures similar hierarchies and alliances. The out-of-session behavioral assignments also aim to shift family unit construction past strengthening or weakening existing family boundaries.⁴ These assignments may include excluding or including family members from certain moments of family life and therefore changing the existing boundaries betwixt particular family members into more advisable ones.

Treatment of J's family unit using structural family therapy. Through careful observation of J's family in the consulting room, a structural family therapist would uncover a dysfunctional structure of his family and piece of work to transform it into a functional one. The boundaries of this family unit were a complex combination of enmeshment and disengagement. The mother and younger sis characterized an enmeshed human relationship and, to a lesser extent, the aforementioned held true for the boundary between J and his mother. On the other hand, J and his stepfather characterized a disengaged relationship.

The hieratical construction of the family was also skewed because the stepfather was at the top, but then a large gap existed between him and the female parent. This placed the mother closer to the children than to the over-ascendant stepfather. Some other dysfunctional element was the palpable brotherhood betwixt J and his mother against his stepfather.

To begin to shift this construction, the therapist recreated the family dialogue that transpired when J'southward stepfather caught him smoking. The therapist was conscientious to ensure that each family member talked to the other person and non well-nigh the other person or the event.

• Psychiatrist: J, can you tell me what yous think about the fourth dimension you were caught smoking?

• J:I was in my room and I thought my parents were still at work when my dad bursts open my door and starting yelling. I was agape he was going to hit me he looked then mad.

• Psychiatrist: Can you look at your dad and tell that story again to him?

• J: I judge….. Dad, I was really scared by you when yous were yelling. I know I did something wrong but….

• Stepfather: (Looking at psychiatrist) I didn't mean to scare him.

• Psychiatrist: Dad, can yous say that to J.

• Stepfather: I didn't mean to scare you lot, but I know you lot are really a adept kid at eye and it hurts me to meet y'all making stupid decisions.

The seating organisation in the room was shifted to represent the desired changes in the bureaucracy and in the alliances of the family unit. The mother and the stepfather were placed together and on equal basis and the children were placed together besides, separated from the mother. To tackle the boundary problems of the family, behavioral assignments were employed to bring J and his stepfather closer together and also to create space between Mother and both J and his younger sister. J and his stepfather were assigned to have up a hobby together once a calendar week and the mother was assigned to join an activity outside of the home to allow both J and his younger sister some fourth dimension and space of their ain.

Strategic Family Therapy

The strategic orientation is "solution focused." The family therapist is responsible for planning a strategy to solve the presenting trouble. Strategic therapy tin be viewed as nigh the opposite of psychodynamic therapy in terms of where emphasis is placed.¹¹ A strategic family therapist focuses on how families can bear differently, not why families behave the fashion they do. The by is largely ignored, while the importance is placed on the present and the current, repetitive family processes.¹²

Modify is brought about past formulating clear goals that target irresolute relational and communication processes within the family.¹¹ The strategic family therapist views the problem as the family's unsuccessful effort at a solution. The therapist recognizes that this unsuccessful attempt exacerbates the problem and plans a successful solution using innovative problem solving strategies. These strategies include such tactics equally reframing, restraining the organization, positioning, and prescribing the symptom.^iv

Reframing challenges the way in which family members perceive the family reality based on their individual perspectives. This challenge reframes the symptom or state of affairs in a less conflicted way and often with a more positive spin. This helps family members see the problem differently and ultimately behave differently.³ Restraining the system is when the therapist discourages change or emphasizes the risks of change in an try to propel the family toward alter equally a reaction against the therapist'due south advice. Positioning is a tactic where the therapist chooses one family unit fellow member's position and agrees with information technology, but exaggerates the position in a style that makes it distasteful. Positioning is often used when two family members concur opposing positions. The goal of this exaggerated and somewhat unpleasant position supported by the therapist is to motivate the family unit member into change. Prescribing the symptom follows the same logic, but must exist used with caution. For this strategy to be successful, the strategic family unit therapist must encourage the very symptom he or she is trying to extinguish. This is done by using a plausible rationale to try to convince the family members that they demand to go along the symptom or problematic behavior to study its effects or even that they need to increment the symptom'south frequency. One must be careful not to seem insincere or manipulative when using this intervention. If washed appropriately, the family unit'southward perception of the symptom is changed from something that is out of its control to something within its control. Once family members perceive they have the ability to alter or manipulate the symptom, the elusive quality of the symptom is gone and replaced by a feeling of control.³ The therapist hopes to unite the family against the therapist'south advice and crusade them to rebel and, therefore, end the problematic behavior on their own.

Handling using strategic family unit therapy. Using the strategic arroyo, the family therapist viewed that the family's unsuccessful attempts to solve the presenting problem actually became the problem. The therapist devised a solution that replaced the unsuccessful attempts with a successful i. A possible approach to creating a "success" for the family'southward problem-solving attempts was to explain that the stepfather'southward reaction to J's smoking was due to the stepfather's obvious business about the wellbeing and future of J. The stepfather'southward extreme reaction was prove of merely how much he cares. This tactic admitted that the stepfather'south reaction may take gone too far, but emphasized the love he had for his stepson and not the bad behavior on either family member's part.

• Psychiatrist: In that location are often multiple ways to view a state of affairs. For case, Dad'due south reaction to catching J smoking was to become aroused. Although at that place may have been a better and less hurtful way of handling the situation, the level of his anger shows but how much he really cares for J. Later on all, if he didn't care much at all for J or his future, he would not care or get angry if J were smoking. J is actually very lucky to have a dad who cares so much virtually him, even if Dad does accept a difficult time showing it sometimes.

• J: Well, it doesn't feel like he cares most of the fourth dimension.

• Stepfather: I hope you lot know that I do love yous and I just want what is best for yous. I am quick to anger, I'll acknowledge that.

• Mother: I agree. We both love yous so much. Mayhap we demand to say that more.

• J: Ok, ok, I get information technology. You care almost me and that is why you care so much when I do bad stuff.

A positioning tactic could be to play off the disagreement between the mother and the stepfather on how to deal with J'southward behavior. The therapist could exaggerate The female parent's position and in the process make it a chip distasteful by explaining that the mother should stick by her son at the expense of her relationship with her married man considering it is obvious that trying to exist both a wife and a mother is too overwhelming for her in her frail, physical condition.

Finally, a way to prescribe the symptom would exist to rationalize with J that it is important to continue to remain depressed to make sure everyone in the family unit tin can feel with him what is information technology like to experience true depression. This will help the family sympathise and empathize with him so that they will no longer be angry virtually his behaviors.

This technique worked to unite the family unit confronting the therapist, with the goals of empowering the mother to balance her human relationship with her husband and her children and helping the stepfather to "back off" and make joint decisions with the mother. This strategy ultimately motivated J to movement across his depression.

Cognitive-Behavioral Family unit Therapy

Cognitive-behavioral family therapy applies many of the bones principles of private cognitive-behavioral therapy. In addition, it also relies heavily on family unit psychoeducation. But equally strategic family therapy can be understood by how it differs from the psychodynamic approach, so can cognitive-behavioral therapy. While the psychodynamic therapist emphasizes the importance of intrapsychic forces, the cognitive-behavioral therapist emphasizes the importance of external social forces.^v In this orientation, all behavior is learning-based and can be unlearned using basic principles of behavior modification. In fact, this type of family unit therapy grew out of behavioral modification programs for young children with deviant behavioral issues.^xiii The cognitive-behavioral family therapist plays the role of a instructor or autobus and brings about alter by understanding the influence family members accept upon each other and utilizing this influence by offering positive and negative reinforcements.^xiv

Techniques employed include operant conditioning, contingency contracting, idea diaries, communication training, and psychoeducation.¹⁵ Operant-workout strategies endeavor to shape behavior through positive and negative reinforcements and may use time-out procedures with younger family unit members. Contingency contracts are behavioral plans family unit members agree to perform that supplant subversive patterns related to the presenting problem. Thought diaries are homework assignments given to family members that track idea patterns with the goal of uncovering and and then correcting common cognitive distortions like catastrophic thinking or overgeneralization. The cognitive-behavioral family unit therapist as well coaches families in fundamental advice skills, such equally how to listen empathically, limited positive feelings, and convey negative communications respectfully.^sixteen Psychoeducation likewise is a primal office of the cognitive-behavioral arroyo to family therapy and can be tailored to each individual family'south needs. Psychoeducation tin can include a broad range of topics from general principles of learning theory to specific information virtually a family fellow member'due south psychiatric diagnosis.

Treatment using cognitive behavioral family therapy. I of the fundamental components of cognitive-behavioral family therapy is operant conditioning, and this tin be used in several ways. Positive reinforcements like time to play his favorite video game or an assart toward his first auto were used to reward J for making proficient grades in school. On the other manus, negative reinforcements were used like non increasing J'southward allowance if he is caught smoking or skipping class. The younger sister's behavior was also modified using operant conditioning. If she stayed dwelling due to a stomachache, the stepfather would stay home with her instead of the mother in order to remove the perceived reward of staying shut to her mother. She also received a prize, her favorite dessert, or a moving-picture show night out if she did not miss whatever schoolhouse for one calendar month.

Communication skills training as well was incorporated. With the therapist as the motorcoach, the skills of listening and sharing feelings and ideas respectfully was practiced in session and so at habitation. This would improve many intrafamily relationships. Psychoeducation is a wise apply of the cognitive behaviorist'south resources in this case, especially in light of the stepfather's belief that psychiatric symptoms were a sign of weakness. The therapist discussed important topics, such as normal adolescent development, signs and symptoms of low, and acrimony management.

Conclusion

Family therapy shifts the focus of the psychiatrist'south attention abroad from the child and onto the family unit as both the source of pathology and the target for handling. It is clear that a child's mental health stems both from genetic factors and from family dynamics. Although a child's genetics cannot, at this time, be modified, the family dynamics are at our disposal.

The historical backdrop and subsequent outgrowth of the different schools of thought about family therapy are similar to the schools of idea nearly private therapy. They arose from the theoretical orientations in the broader mental wellness community and sometimes from reactions against before orientations. Although several different schools of family therapy exist and strategies of recommended treatment differ, contemporary family unit therapy that utilizes a multimodal arroyo incorporates insights and techniques from each school of thought based on an individual family's needs and the therapist'southward style.ⁱⁱⁱ

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719446/

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