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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
Dr. Schwartz's Weblog

Family Therapy: A Different Approach to Psychotherapy

Allan N. Schwartz, LCSW, Ph.D. Updated: Mar 31st 2009

 One of the important things to keep in mind if you are thinking about psychotherapy is Family Therapy. While the tendency is for people to look for individual psychotherapy for such things as depression, anxiety and other behavioral disorders, there is an important place that Family Therapy holds among the types and varieties of treatment approaches. In fact, there are times when Family Therapy takes on a special type of importance due to the type of disorder that has been brought to the therapist.

For example, behavioral disorders involving children such as ADHD, eating disorders, defiant disorders, or adult problems such as alcoholism, drug abuse, marriage problems, etc, all lend themselves nicely to family therapy. I hear the reader asking "WHY?"

In answering the question "Why" with regard to Family Therapy, a general summary of family therapy thinking will be given here without going into the different schools and types of this treatment. Suffice it to say that, from the point of view of the family therapist, the family is a type of "system" or "machine."

The view that the individual therapist has of human behavior is very different from the way that behavior is seen by a family therapist. For the individual therapist, such as a psychologist, social worker or psychiatrist, a person comes to the consulting room looking for relief from some type of problem causing them to feel depressed, angry, anxious, sleepless  and etc. By using a variety of approaches, such as Cognitive Behavioral Therapy, EMDR, Medications, Psychodynamic therapy or Psychoanalysis, the therapist and patient work together to improve functioning and, therefore, to control or eliminate symptoms. In other words, cure the client or patient and the problem is solved.

Family therapists might not agree with this conclusion because their concern is that the problem is not solved. Why not? They would answer by pointing out that the individual is part of a "system" or part of a "machine" that functions by maintaining all of its various parts. Change something in one part of the system and the remainder will operate to restore the system to its original balance or status.

Hypothetical Case Example:

"A morbidly obese man is referred to an individual therapist who has a well deserved reputation as an eating disorder specialist. He works with the patient for an entire year, seeing him twice per week, so that they can work on such things as his eating behaviors including the cues that set off his binges. The approach is basically cognitive behavioral. This obese man also sees a licensed nutritionist who works cooperatively with the therapist. During the year, the patient begins to lose weight in a way that is gradual and sensible. Therapist and nutritionist are careful to work with the patient on how he is experiencing this weight loss, aware that this man is heavily and emotionally invested in his huge size. Progress is excellent.

However, three quarters of the way through the year the patient begins to gain weight. He refuses to see the nutritionist, stating that he does not have enough money to pay all of the fees for his treatment. This becomes the reason for his reducing his sessions with the therapist from twice weekly to once every other week.

Ultimately, the man not only regains all of the weight he lost but significantly and dangerously more. Suspecting that there was more going on in this man's life that he was revealing in therapy, he is referred by the therapist to a well know family therapist.

The family therapist manages to get the man's extended family into the office for several meeting where it is revealed that the patient ran into huge amounts of pressure to resume his former weight. Of course, no one in the family, his mother, father and sisters, would admit to this, but they wanted him to be heavy as a way of keeping him safely within the confines of the family where he would remain. In other words, weight loss came to be perceived as a threat to the continued existence of this family system, dysfunctional as it was."

Going back to a principle of physics, "for every action there is an equal and opposite reaction." Attempt to bring unwanted change into a family system and the people who comprise that system will join and bring pressure to maintain the status quo.

I have seen this type of thing happen with attempts to treat alcoholism, drug abuse and many other types of disorders. On the surface it may appear that a family wants their sick or malfunctioning kin to recover. However, just under that surface and out of any conscious awareness are great fears and pressures to prevent anything or anyone from changing.

The family therapist:

Functioning in a very different way from the individual therapist, the family therapist inserts his/her self into the family system. This is very "tricky" business because, while becoming a member of the system, the therapist must maintain objectivity so that he does not become ensnared in that dysfunctional system.

The family sits in a circle in the consulting room and the therapist is part of that circle. Depending on the approach used to this type of therapy, the therapist may re assign seating arrangements during the course of the treatments in order to shake up the process of making alliances among members, something that is quite usual in the history and life of any family.

One of the interesting aspects of this type of therapy is that no one person is necessarily viewed as the one who is "sick" or troubled. If someone is viewed in that way, there is an opportunity to look at why and what purpose is being served by this member being assigned the role of sick person. Gradually, the malfunctioning system is restored to healthy functioning so that individual members can grow and change without the system feeling threatened. A new status quo or balance is attained to everyone's benefit.

It is common, because of the number of people involved in a family unit and the complexities involved, for more than one therapist to be part of the process of treatment. Some teams even use, with the consent of everyone present, video taping of sessions with replay made available to the family members. Also, more than one therapist in the room makes it less likely that any important interactions do not escape view because so much can happen and very fast.

I am reminded of a wonderful movie from the past that illustrates the forces to which a family can be subjected outside of awareness. The movie, from the 1950's is entitled Marty. Marty is a middle aged bachelor who lives with his mother in an Italian section of the Bronx. His mother constantly pushes her son to find a nice girl, settle down and get married. Finally one evening out, Mary meets a woman and falls in love with her. To his surprise, his mother suddenly becomes disapproving of this girl and attempts to discourage him. Unbeknownst to Mary, his mother has been talking to her sister who warns her that she will be left abandoned if Marty marries. Enormous pressure is brought to bear on Marty by his mother and with a heavy dosage of guilt. Ultimately, Marty breaks away from the guilt and marries the woman. His mother and aunt, her sister, move in with one another and settle into a new life that neither one of them is happy with. However, life goes on as it should.

This is why it is often vitally important to have some type of family therapy involved even in the context of working with an individual patient. Teenage girls suffering with Anorexia, often need to have family involved because so many kin are involved in maintaining the low weight of the young woman. The reasons for this are varied and complex and that is why no one factor will hold true for all family systems.

For example, a young teenage girl who is struggling with Anorexia, may be striving towards perfection as a way to please her parents. Her parents, successful professionals, may stress perfection in their daugher and hold extremely high expectations of her without being aware of the impact this is having on her. Left with only one way to accomplish her goals, she strives towards being as thin as she possibly can.

Another family has a daughter who has Bulimia and a son who is abusing drugs. Unware of what they were doing, the parents set up a system where no one had any real privacy in the family. Everyone barged into the daughter's bedroom where the family televison was located. The mother would go through everyone's dresser drawers and desks ignoring their needs for privacy.

None of these examples have anything to do with "bad people" or even abusive people. It is just that families can slip into dysfunctional patterns of behavior that negatively impact on all involved. This is where family therapy comes in.

Your questions and comments are encouraged.

Allan N. Schwartz, LCSW, PhD

Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at dransphd@aol.com for details.

    Reader Comments
    Discuss this issue below or in our forums.

    Family Therapy - Allan N. Schwartz, PhD - Sep 19th 2009

    While I cannot say that I know anything about "restructuring family therapy," I can say that all family therapy is restrucuring in nature and that in the case of substance abuse and many other problems, there is a family basis for the issue.

    For example, if you or/and your husband have a history of substance abuse (I am not implying that you do) then your son's abuse is part of a family pattern.

    Another example is that if you and/or your husband unwittlingly encourage your son to abuse substances then when he returns home he will fall back into that behavior unless you and your husband learn to handle things differently.

    Anyway, this is not meant to mean that you or the family is at fault. It is NOT a matter of blame. We all have families and we all have patterns in those families. It is important to learn new and improved patterns and this benefits not one person but everyone.

    I have done family therapy and studied it and I am convinced of its value.

    Dr. Schwartz

    To ses, Re: 18 yr old son in rehab - Seth - Sep 19th 2009

    It is hard to respond to your comment about your son, "not doing well".  Would need to know more.  However, I can offer a couple of things to consider.  First off, it is likely that your son is in a 12 step treatment, since most facilities are.  I would be very careful about how you come across to your son if he is uncomfortable, frustrated, or offended by the philosophy offered in treatment.  Be sure to accurately and genuinely convey your desire for your son to be happy and overcome his struggles in a way that he will not misinterpret as you placing a higher value on the treatment philosophy than him.  Many parents, however unknowingly, and out of desperation to keep their child safe, will accuse the child of somehow defying the support or help in treatment and associate that "defiance" with his unwillingness or inability to "recover", rather than recognize his disdain for the principles as a sign of something positive within him and evidence that there is a better way for him, outside of 12 steps.  It is often the case that exposure (especially aggressive exposure) to 12 step treatment can be a profound irritant to someone's struggles and stand in the way of successful treatment rather than support a successful treatment.  Be loyal to your son - not the treatment center or it's staff, or the public consensus that 12 step treatment is "the answer".  Otherwise, whatever issues which stand in the way of a harmonious parent/child relationship will be exacerbated, to say the least and it is likely that your son will seek further "relief" through alcohol and/or drugs.

    Family Therapy can be very effective, but as is always the case, it's effectiveness is contingent upon the openness, compassion, understanding and integrity of all the players - including the therapist.  Choose wisely.  One thing that parents sometimes fail to see is that any profound change requires an individual to stray far outside his comfort zone to face the issues that, for all intents and purposes, created the boundaries of that comfort zone.  If parents wish to support his or her child, they too have to stray outside comfort zones, which in truth, forces (or inspires) the parents to also face issues.  Parents cannot expect their child to face issues while within the process, refusing to face their own issues, at which point they become a hindrance to the process, however inadvertently.  It is complicated stuff, really.  So if throughout your son's therapy process, you are able to respond differently, look at things differently, be honest with yourself, relate to his struggles (since, regardless of how they may have manifested differently, you have your own version of), and in general be willing to work as diligently as you expect your son to, then I can see a wonderful result come about from family therapy. One of the things that parents sometimes fail to do is reconsider their position on things.  If somehow throughout his upbringing you demanded that he make his bed every day, for example, and his interpretation of it left him feeling that a made bed was more important than him, he may live the rest of his life refusing to make his bed as an attempt to preserve his self worth.  If something like that surfaces throughout therapy, rather than defending your position that making a bed is important and an honorable discipline strategy, wrap your arms around your son, tell him you are sorry that he ever felt unimportant - or ever felt badly in anyway and that if it came down to a made bed or a happy, fulfilled son, you would choose him - any day of the week.  Ironically, the result could very well be a happy son who makes his bed every day.  Silly example, I admit, but I hope you get the point. 

    Best of luck with your son.  He is young, yet.  Be open to discovering that his issues are unique to him and while drugs and alcohol may be his specific source of relief or distraction and on their own, can have a devastating effect on a young life and his family, the emphasis and focus is much better placed on the deeper issues, which compelled him to seek relief in the first place. 

     

    Family Restructuring Therapy - ses - Sep 18th 2009

    My 18 year old son is in rehab for drug and alcohol abuse. He is not doing well and it has been suggested that my husband and I participate in family restructuring therapy. We will stay at the facility with our son for two weeks and attend therapy..does anyone have information on this type of therapy , pros ,cons, successes?

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