What is Family Therapy?

Introduction

Family therapy, also referred to as couple and family therapy, marriage and family therapy, family systems therapy, and family counselling, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of interaction between family members.

The different schools of family therapy have in common a belief that, regardless of the origin of the problem, and regardless of whether the clients consider it an “individual” or “family” issue, involving families in solutions often benefits clients. This involvement of families is commonly accomplished by their direct participation in the therapy session. The skills of the family therapist thus include the ability to influence conversations in a way that catalyses the strengths, wisdom, and support of the wider system.

In the field’s early years, many clinicians defined the family in a narrow, traditional manner usually including parents and children. As the field has evolved, the concept of the family is more commonly defined in terms of strongly supportive, long-term roles and relationships between people who may or may not be related by blood or marriage.

The conceptual frameworks developed by family therapists, especially those of family systems theorists, have been applied to a wide range of human behaviour, including organisational dynamics and the study of greatness.

Brief History and Theoretical Frameworks

Formal interventions with families to help individuals and families experiencing various kinds of problems have been a part of many cultures, probably throughout history. These interventions have sometimes involved formal procedures or rituals, and often included the extended family as well as non-kin members of the community (see for example Ho’oponopono). Following the emergence of specialisation in various societies, these interventions were often conducted by particular members of a community – for example, a chief, priest, physician, and so on – usually as an ancillary function.

Family therapy as a distinct professional practice within Western cultures can be argued to have had its origins in the social work movements of the 19th century in the United Kingdom and the United States. As a branch of psychotherapy, its roots can be traced somewhat later to the early 20th century with the emergence of the child guidance movement and marriage counselling. The formal development of family therapy dates from the 1940s and early 1950s with the founding in 1942 of the American Association of Marriage Counsellors (the precursor of the AAMFT), and through the work of various independent clinicians and groups – in the United Kingdom (John Bowlby at the Tavistock Clinic), the United States (Donald deAvila Jackson, John Elderkin Bell, Nathan Ackerman, Christian Midelfort, Theodore Lidz, Lyman Wynne, Murray Bowen, Carl Whitaker, Virginia Satir, Ivan Boszormenyi-Nagy), and in Hungary, D.L.P. Liebermann – who began seeing family members together for observation or therapy sessions. There was initially a strong influence from psychoanalysis (most of the early founders of the field had psychoanalytic backgrounds) and social psychiatry, and later from learning theory and behaviour therapy – and significantly, these clinicians began to articulate various theories about the nature and functioning of the family as an entity that was more than a mere aggregation of individuals.

The movement received an important boost starting in the early 1950s through the work of anthropologist Gregory Bateson and colleagues – Jay Haley, Donald D. Jackson, John Weakland, William Fry, and later, Virginia Satir, Ivan Boszormenyi-Nagy, Paul Watzlawick and others – at Palo Alto in the United States, who introduced ideas from cybernetics and general systems theory into social psychology and psychotherapy, focusing in particular on the role of communication (refer to Bateson Project). This approach eschewed the traditional focus on individual psychology and historical factors – that involve so-called linear causation and content – and emphasized instead feedback and homeostatic mechanisms and “rules” in here-and-now interactions – so-called circular causation and process – that were thought to maintain or exacerbate problems, whatever the original cause(s). This group was also influenced significantly by the work of US psychiatrist, hypnotherapist, and brief therapist, Milton H. Erickson – especially his innovative use of strategies for change, such as paradoxical directives. The members of the Bateson Project (like the founders of a number of other schools of family therapy, including Carl Whitaker, Murray Bowen, and Ivan Boszormenyi-Nagy) had a particular interest in the possible psychosocial causes and treatment of schizophrenia, especially in terms of the putative “meaning” and “function” of signs and symptoms within the family system. The research of psychiatrists and psychoanalysts Lyman Wynne and Theodore Lidz on communication deviance and roles (e.g. pseudo-mutuality, pseudo-hostility, schism and skew) in families of people with schizophrenia also became influential with systems-communications-oriented theorists and therapists. A related theme, applying to dysfunction and psychopathology more generally, was that of the “identified patient” or “presenting problem” as a manifestation of or surrogate for the family’s, or even society’s, problems (refer to Double Bind).

By the mid-1960s, a number of distinct schools of family therapy had emerged. From those groups that were most strongly influenced by cybernetics and systems theory, there came MRI Brief Therapy, and slightly later, strategic therapy, Salvador Minuchin’s Structural Family Therapy and the Milan systems model. Partly in reaction to some aspects of these systemic models, came the experiential approaches of Virginia Satir and Carl Whitaker, which downplayed theoretical constructs, and emphasized subjective experience and unexpressed feelings (including the subconscious), authentic communication, spontaneity, creativity, total therapist engagement, and often included the extended family. Concurrently and somewhat independently, there emerged the various intergenerational therapies of Murray Bowen, Ivan Boszormenyi-Nagy, James Framo, and Norman Paul, which present different theories about the intergenerational transmission of health and dysfunction, but which all deal usually with at least three generations of a family (in person or conceptually), either directly in therapy sessions, or via “homework”, “journeys home”, etc. Psychodynamic family therapy – which, more than any other school of family therapy, deals directly with individual psychology and the unconscious in the context of current relationships – continued to develop through a number of groups that were influenced by the ideas and methods of Nathan Ackerman, and also by the British School of Object Relations and John Bowlby’s work on attachment. Multiple-family group therapy, a precursor of psychoeducational family intervention, emerged, in part, as a pragmatic alternative form of intervention – especially as an adjunct to the treatment of serious mental disorders with a significant biological basis, such as schizophrenia – and represented something of a conceptual challenge to some of the “systemic” (and thus potentially “family-blaming”) paradigms of pathogenesis that were implicit in many of the dominant models of family therapy. The late-1960s and early-1970s saw the development of network therapy (which bears some resemblance to traditional practices such as Ho’oponopono) by Ross Speck and Carolyn Attneave, and the emergence of behavioural marital therapy (renamed behavioural couples therapy in the 1990s; see also relationship counselling) and behavioural family therapy as models in their own right.

By the late-1970s, the weight of clinical experience – especially in relation to the treatment of serious mental disorders – had led to some revision of a number of the original models and a moderation of some of the earlier stridency and theoretical purism. There were the beginnings of a general softening of the strict demarcations between schools, with moves toward rapprochement, integration, and eclecticism – although there was, nevertheless, some hardening of positions within some schools. These trends were reflected in and influenced by lively debates within the field and critiques from various sources, including feminism and post-modernism, that reflected in part the cultural and political tenor of the times, and which foreshadowed the emergence (in the 1980s and 1990s) of the various “post-systems” constructivist and social constructionist approaches. While there was still debate within the field about whether, or to what degree, the systemic-constructivist and medical-biological paradigms were necessarily antithetical to each other (refer to Anti-psychiatry; Biopsychosocial model), there was a growing willingness and tendency on the part of family therapists to work in multi-modal clinical partnerships with other members of the helping and medical professions.

From the mid-1980s to the present, the field has been marked by a diversity of approaches that partly reflect the original schools, but which also draw on other theories and methods from individual psychotherapy and elsewhere – these approaches and sources include: brief therapy, structural therapy, constructivist approaches (e.g. Milan systems, post-Milan/collaborative/conversational, reflective), Bring forthism approach (e.g. Dr. Karl Tomm’s IPscope model and Interventive interviewing), solution-focused therapy, narrative therapy, a range of cognitive and behavioural approaches, psychodynamic and object relations approaches, attachment and emotionally focused therapy, intergenerational approaches, network therapy, and multi-systemic therapy (MST). Multicultural, intercultural, and integrative approaches are being developed, with Vincenzo Di Nicola weaving a synthesis of family therapy and transcultural psychiatry in his model of cultural family therapy, A Stranger in the Family: Culture, Families, and Therapy. Many practitioners claim to be “eclectic”, using techniques from several areas, depending upon their own inclinations and/or the needs of the client(s), and there is a growing movement toward a single “generic” family therapy that seeks to incorporate the best of the accumulated knowledge in the field and which can be adapted to many different contexts; however, there are still a significant number of therapists who adhere more or less strictly to a particular, or limited number of, approach(es).

The Liberation Based Healing framework for family therapy offers a complete paradigm shift for working with families while addressing the intersections of race, class, gender identity, sexual orientation and other socio-political identity markers. This theoretical approach and praxis is informed by Critical Pedagogy, Feminism, Critical Race Theory, and Decolonising Theory. This framework necessitates an understanding of the ways Colonisation, Cis-Heteronormativity, Patriarchy, White Supremacy and other systems of domination impact individuals, families and communities and centres the need to disrupt the status quo in how power operates. Traditional Western models of family therapy have historically ignored these dimensions and when white, male privilege has been critiqued, largely by feminist theory practitioners, it has often been to the benefit of middle class, white women’s experiences. While an understanding of intersectionality is of particular significance in working with families with violence, a liberatory framework examines how power, privilege and oppression operate within and across all relationships. Liberatory practices are based on the principles of Critical-Consciousness, Accountability and Empowerment. These principles guide not only the content of the therapeutic work with clients but also the supervisory and training process of therapists. Dr. Rhea Almeida, developed the Cultural Context Model as a way to operationalize these concepts into practice through the integration of culture circles, sponsors, and a socio-educational process within the therapeutic work.

Ideas and methods from family therapy have been influential in psychotherapy generally: a survey of over 2,500 US therapists in 2006 revealed that of the 10 most influential therapists of the previous quarter-century, three were prominent family therapists and that the marital and family systems model was the second most utilised model after cognitive behavioural therapy.

Techniques

Family therapy uses a range of counselling and other techniques including:

  • Structural therapy – identifies and re-orders the organisation of the family system.
  • Strategic therapy – looks at patterns of interactions between family members.
  • Systemic/Milan therapy – focuses on belief systems.
  • Narrative therapy – restoring of dominant problem-saturated narrative, emphasis on context, separation of the problem from the person.
  • Transgenerational therapy – transgenerational transmission of unhelpful patterns of belief and behaviour.
  • IPscope model and Interventive Interviewing.
  • Communication theory.
  • Psychoeducation.
  • Psychotherapy.
  • Relationship counselling.
  • Relationship education.
  • Systemic coaching.
  • Systems theory.
  • Reality therapy.
  • The genogram.

The number of sessions depends on the situation, but the average is 5-20 sessions. A family therapist usually meets several members of the family at the same time. This has the advantage of making differences between the ways family members perceive mutual relations as well as interaction patterns in the session apparent both for the therapist and the family. These patterns frequently mirror habitual interaction patterns at home, even though the therapist is now incorporated into the family system. Therapy interventions usually focus on relationship patterns rather than on analysing impulses of the unconscious mind or early childhood trauma of individuals as a Freudian therapist would do – although some schools of family therapy, for example psychodynamic and intergenerational, do consider such individual and historical factors (thus embracing both linear and circular causation) and they may use instruments such as the genogram to help to elucidate the patterns of relationship across generations.

The distinctive feature of family therapy is its perspective and analytical framework rather than the number of people present at a therapy session. Specifically, family therapists are relational therapists: They are generally more interested in what goes on between individuals rather than within one or more individuals, although some family therapists – in particular those who identify as psychodynamic, object relations, intergenerational, or experiential family therapists (EFTs) – tend to be as interested in individuals as in the systems those individuals and their relationships constitute. Depending on the conflicts at issue and the progress of therapy to date, a therapist may focus on analysing specific previous instances of conflict, as by reviewing a past incident and suggesting alternative ways family members might have responded to one another during it, or instead proceed directly to addressing the sources of conflict at a more abstract level, as by pointing out patterns of interaction that the family might have not noticed.

Family therapists tend to be more interested in the maintenance and/or solving of problems rather than in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to allocate blame to one or more individuals, with the effect that for many families a focus on causation is of little or no clinical utility. It is important to note that a circular way of problem evaluation is used as opposed to a linear route. Using this method, families can be helped by finding patterns of behaviour, what the causes are, and what can be done to better their situation.

Summary of Theories and Techniques

Theoretical ModelTheoristsSummaryTechniques
Adlerian family therapyAlfred AdlerAlso known as “individual psychology”. Sees the person as a whole. Ideas include compensation for feelings of inferiority leading to striving for significance toward a fictional final goal with a private logic. Birth order and mistaken goals are explored to examine mistaken motivations of children and adults in the family constellation.Psychoanalysis, typical day, reorienting, re-educating
Attachment theoryJohn Bowlby, Mary Ainsworth, Douglas HaldaneIndividuals are shaped by their experiences with caregivers in the first three years of life. Used as a foundation for Object Relations Theory. The Strange Situation experiment with infants involves a systematic process of leaving a child alone in a room in order to assess the quality of their parental bond.Psychoanalysis, play therapy
Bowenian family systems therapyMurray Bowen, Betty Carter, Philip Guerin, Michael Kerr, Thomas Fogarty, Monica McGoldrick, Edwin Friedman, Daniel PaperoAlso known as “intergenerational family therapy” (although there are also other schools of intergenerational family therapy). Family members are driven to achieve a balance of internal and external differentiation, causing anxiety, triangulation, and emotional cutoff. Families are affected by nuclear family emotional processes, sibling positions and multigenerational transmission patterns resulting in an undifferentiated family ego mass.Detriangulation, non-anxious presence, genograms, coaching
Cognitive behavioural family therapyJohn Gottman, Albert Ellis, Albert BanduraProblems are the result of operant conditioning that reinforces negative behaviours within the family’s interpersonal social exchanges that extinguish desired behaviour and promote incentives toward unwanted behaviours. This can lead to irrational beliefs and a faulty family schema.Therapeutic contracts, modelling, systematic desensitisation, shaping, charting, examining irrational beliefs
Collaborative language systems therapyHarry Goolishian, Harlene Anderson, Tom Andersen, Lynn Hoffman, Peggy PennIndividuals form meanings about their experiences within the context of social relationship on a personal and organisational level. Collaborative therapists help families reorganise and dis-solve their perceived problems through a transparent dialogue about inner thoughts with a “not-knowing” stance intended to illicit new meaning through conversation. Collaborative therapy is an approach that avoids a particular theoretical perspective in favour of a client-centred philosophical process.Dialogical conversation, not knowing, curiosity, being public, reflecting teams
Communications approachesVirginia Satir, John Banmen, Jane Gerber, Maria GomoriAll people are born into a primary survival triad between themselves and their parents where they adopt survival stances to protect their self-worth from threats communicated by words and behaviours of their family members. Experiential therapists are interested in altering the overt and covert messages between family members that affect their body, mind and feelings in order to promote congruence and to validate each person’s inherent self-worth.Equality, modelling communication, family life chronology, family sculpting, metaphors, family reconstruction
Contextual therapyIvan Boszormenyi-NagyFamilies are built upon an unconscious network of implicit loyalties between parents and children that can be damaged when these “relational ethics” of fairness, trust, entitlement, mutuality and merit are breached.Rebalancing, family negotiations, validation, filial debt repayment
Cultural family therapyVincenzo Di Nicola
Key influences: Celia Falicov, Antonio Ferreira, James Framo, Edwin Friedman, Mara Selvini Palazzoli, Carlos Sluzki, Victor Turner, Michael White
A synthesis of systemic family therapy with cultural psychiatry to create cultural family therapy (CFT). CFT is an interweaving of stories (family predicaments expressed in narratives of family life) and tools (clinical methods for working with and making sense of these stories in cultural context). Integrates and synthesizes systemic therapy and cultural and medical anthropology with narrative therapy.Conceptual tools for working across cultures – spirals, masks, roles, codes, cultural strategies, bridges, stories, multiple codes (metaphor and somatics), therapy as “story repair”
Emotion-focused therapySue Johnson, Les GreenbergCouples and families can develop rigid patterns of interaction based on powerful emotional experiences that hinder emotional engagement and trust. Treatment aims to enhance empathic capabilities of family members by exploring deep-seated habits and modifying emotional cues.Reflecting, validation, heightening, reframing, restructuring
Experiential family therapyCarl Whitaker, David Keith, Laura Roberto, Walter Kempler, John Warkentin, Thomas Malone, August NapierStemming from Gestalt foundations, change and growth occurs through an existential encounter with a therapist who is intentionally “real” and authentic with clients without pretence, often in a playful and sometimes absurd way as a means to foster flexibility in the family and promote individuation.Battling, constructive anxiety, redefining symptoms, affective confrontation, co-therapy, humour
Family mode deactivation therapy (FMDT)Jack A. ApscheTarget population adolescents with conduct and behavioural problems. Based on schema theory. Integrate mindfulness to focus family on the present. Validate core beliefs based on past experiences. Offer viable alternative responses. Treatment is based on case conceptualisation process; validate and clarify core beliefs, fears, triggers, and behaviours. Redirect behaviour by anticipating triggers and realigning beliefs and fears.Cognitive behavioural therapy, mindfulness, acceptance and commitment therapy, dialectical behaviour therapy, defusion, validate-clarify-redirect
Family-of-origin therapyJames FramoHe developed an object relations approach to intergenerational and family-of-origin therapy.Working with several generations of the family, family-of-origin approach with families in therapy and with trainees
Feminist family therapySandra Bem Marianne WaltersComplications from social and political disparity between genders are identified as underlying causes of conflict within a family system. Therapists are encouraged to be aware of these influences in order to avoid perpetuating hidden oppression, biases and cultural stereotypes and to model an egalitarian perspective of healthy family relationships.Demystifying, modelling, equality, personal accountability
Milan systemic family therapyLuigi Boscolo, Gianfranco Cecchin, Mara Selvini Palazzoli, Giuliana PrataA practical attempt by the “Milan Group” to establish therapeutic techniques based on Gregory Bateson’s cybernetics that disrupts unseen systemic patterns of control and games between family members by challenging erroneous family beliefs and reworking the family’s linguistic assumptions.Hypothesizing, circular questioning, neutrality, counter-paradox
MRI brief therapyGregory Bateson, Milton Erickson, Heinz von FoersterEstablished by the Mental Research Institute (MRI) as a synthesis of ideas from multiple theorists in order to interrupt misguided attempts by families to create first and second order change by persisting with “more of the same”, mixed signals from unclear metacommunication and paradoxical double-bind messages.Reframing, prescribing the symptom, relabelling, restraining (going slow), Bellac Ploy
Narrative therapyMichael White, David EpstonPeople use stories to make sense of their experience and to establish their identity as a social and political constructs based on local knowledge. Narrative therapists avoid marginalising their clients by positioning themselves as a co-editor of their reality with the idea that “the person is not the problem, but the problem is the problem.”Deconstruction, externalising problems, mapping, asking permission
Object relations therapyHazan & Shaver, David Scharff & Jill Scharff, James FramoIndividuals choose relationships that attempt to heal insecure attachments from childhood. Negative patterns established by their parents (object) are projected onto their partners.Detriangulation, co-therapy, psychoanalysis, holding environment
Psychoanalytic family therapyNathan AckermanBy applying the strategies of Freudian psychoanalysis to the family system therapists can gain insight into the interlocking psychopathologies of the family members and seek to improve complementarity.Psychoanalysis, authenticity, joining, confrontation
Solution focused therapyKim Insoo Berg, Steve de Shazer, William O’Hanlon, Michelle Weiner-Davis, Paul WatzlawickThe inevitable onset of constant change leads to negative interpretations of the past and language that shapes the meaning of an individual’s situation, diminishing their hope and causing them to overlook their own strengths and resources.Future focus, beginner’s mind, miracle question, goal setting, scaling
Strategic therapyJay Haley, Cloe MadanesSymptoms of dysfunction are purposeful in maintaining homeostasis in the family hierarchy as it transitions through various stages in the family life cycle.Directives, paradoxical injunctions, positioning, metaphoric tasks, restraining (going slow)
Structural family therapySalvador Minuchin, Harry Aponte, Charles Fishman, Braulio MontalvoFamily problems arise from maladaptive boundaries and subsystems that are created within the overall family system of rules and rituals that governs their interactions.Joining, family mapping, hypothesizing, re-enactments, reframing, unbalancing

Evidence Base

Family therapy has an evolving evidence base. A summary of current evidence is available via the UK’s Association of Family Therapy. Evaluation and outcome studies can also be found on the Family Therapy and Systemic Research Centre website. The website also includes quantitative and qualitative research studies of many aspects of family therapy.

According to a 2004 French government study conducted by French Institute of Health and Medical Research, family and couples therapy was the second most effective therapy after Cognitive behavioural therapy. The study used meta-analysis of over a hundred secondary studies to find some level of effectiveness that was either “proven” or “presumed” to exist. Of the treatments studied, family therapy was presumed or proven effective at treating schizophrenia, bipolar disorder, anorexia and alcohol dependency.

Concerns and Criticism

In a 1999 address to the Coalition of Marriage, Family and Couples Education conference in Washington, D.C., University of Minnesota Professor William Doherty said:

“I take no joy in being a whistle blower, but it’s time. I am a committed marriage and family therapist, having practiced this form of therapy since 1977. I train marriage and family therapists. I believe that marriage therapy can be very helpful in the hands of therapists who are committed to the profession and the practice. But there are a lot of problems out there with the practice of therapy – a lot of problems.”

Doherty suggested questions prospective clients should ask a therapist before beginning treatment:

  1. “Can you describe your background and training in marital therapy?”
  2. “What is your attitude toward salvaging a troubled marriage versus helping couples break up?”
  3. “What is your approach when one partner is seriously considering ending the marriage and the other wants to save it?”
  4. “What percentage of your practice is marital therapy?”
  5. “Of the couples you treat, what percentage would you say work out enough of their problems to stay married with a reasonable amount of satisfaction with the relationship.” “What percentage break up while they are seeing you?” “What percentage do not improve?” “What do you think makes the differences in these results?”

Licensing and Degrees

Family therapy practitioners come from a range of professional backgrounds, and some are specifically qualified or licensed/registered in family therapy (licensing is not required in some jurisdictions and requirements vary from place to place). In the United Kingdom, family therapists will have a prior relevant professional training in one of the helping professions usually psychologists, psychotherapists, or counsellors who have done further training in family therapy, either a diploma or an M.Sc. In the United States there is a specific degree and license as a marriage and family therapist; however, psychologists, nurses, psychotherapists, social workers, or counsellors, and other licensed mental health professionals may practice family therapy. In the UK, family therapists who have completed a four-year qualifying programme of study (MSc) are eligible to register with the professional body the Association of Family Therapy (AFT), and with the UK Council for Psychotherapy (UKCP).

A master’s degree is required to work as a Marriage and Family Therapist (MFT) in some American states. Most commonly, MFTs will first earn a M.S. or M.A. degree in marriage and family therapy, counselling, psychology, family studies, or social work. After graduation, prospective MFTs work as interns under the supervision of a licensed professional and are referred to as an MFTi.

Prior to 1999 in California, counsellors who specialised in this area were called Marriage, Family and Child Counsellors. Today, they are known as Marriage and Family Therapists (MFT), and work variously in private practice, in clinical settings such as hospitals, institutions, or counselling organisations.

Marriage and family therapists in the United States and Canada often seek degrees from accredited Masters or Doctoral programmes recognised by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), a division of the American Association of Marriage and Family Therapy.

Requirements vary, but in most states about 3,000 hours of supervised work as an intern are needed to sit for a licensing exam. MFTs must be licensed by the state to practice. Only after completing their education and internship and passing the state licensing exam can a person call themselves a Marital and Family Therapist and work unsupervised.

License restrictions can vary considerably from state to state. Contact information about licensing boards in the United States are provided by the Association of Marital and Family Regulatory Boards.

There have been concerns raised within the profession about the fact that specialist training in couples therapy – as distinct from family therapy in general – is not required to gain a license as an MFT or membership of the main professional body, the AAMFT.

Values and Ethics

Since issues of interpersonal conflict, power, control, values, and ethics are often more pronounced in relationship therapy than in individual therapy, there has been debate within the profession about the different values that are implicit in the various theoretical models of therapy and the role of the therapist’s own values in the therapeutic process, and how prospective clients should best go about finding a therapist whose values and objectives are most consistent with their own. An early paper on ethics in family therapy written by Vincenzo Di Nicola in consultation with a bioethicist asked basic questions about whether strategic interventions “mean what they say” and if it is ethical to invent opinions offered to families about the treatment process, such as statements saying that half of the treatment team believes one thing and half believes another. Specific issues that have emerged have included an increasing questioning of the longstanding notion of therapeutic neutrality, a concern with questions of justice and self-determination, connectedness and independence, “functioning” versus “authenticity”, and questions about the degree of the therapist’s “pro-marriage/family” versus “pro-individual” commitment.

The American Association for Marriage and Family Therapy requires members to adhere to a “Code of Ethics”, including a commitment to “continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship.”

Founders and Key Influences

Some key developers of family therapy are:

  • Alfred Adler (individual psychology).
  • Nathan Ackerman (psychoanalytic).
  • Tom Andersen (reflecting practices and dialogues about dialogues).
  • Harlene Anderson (postmodern collaborative therapy and Collaborative Language Systems).
  • Maurizio Andolfi (interactional, integrative, multigenerational, and relational family therapy).
  • Harry J Aponte (Person-of-the-Therapist).
  • Jack A. Apsche (family mode deactivation therapy, FMDT).
  • Gregory Bateson (1904–1980) (cybernetics, systems theory).
  • Ivan Boszormenyi-Nagy (contextual therapy, intergenerational, relational ethics).
  • Murray Bowen (systems theory, intergenerational).
  • Steve de Shazer (solution focused therapy).
  • Vincenzo Di Nicola (cultural family therapy).
  • Milton H. Erickson (hypnotherapy, strategic therapy, brief therapy).
  • Richard Fisch (brief therapy, strategic therapy).
  • James Framo (object relations theory, intergenerational, family-of-origin therapy).
  • Edwin Friedman (family process in religious congregations).
  • Harry Goolishian (postmodern collaborative therapy and collaborative language systems).
  • John Gottman (marriage).
  • Robert-Jay Green (LGBT, cross-cultural issues).
  • Douglas Haldane (Attachment-based couple therapist).
  • Jay Haley (strategic therapy, communications).
  • Lynn Hoffman (strategic, post-systems, collaborative).
  • Don D. Jackson (systems theory).
  • Sue Johnson (emotionally focused therapy, attachment theory).
  • Walter Kempler (Gestalt psychology).
  • Cloe Madanes (strategic therapy).
  • Salvador Minuchin (structural family therapy).
  • Braulio Montalvo (structural family therapy).
  • Virginia Satir (communications, experiential, conjoint and co-therapy).
  • Mara Selvini Palazzoli (Milan family systems therapy).
  • Karl Tomm (IPscope model and interventive interviewing, Bringforthism).
  • Robin Skynner (group analysis).
  • Paul Watzlawick (brief therapy, systems theory).
  • John Weakland (brief therapy, strategic therapy, systems theory).
  • Carl Whitaker (family systems, experiential, co-therapy).
  • Michael White (narrative therapy).
  • Lyman Wynne (schizophrenia, pseudomutuality).

What is Multiple Impact Therapy?

Introduction

Multiple impact therapy (MIT) is a group psychotherapy technique most often used with families in extreme crisis.

It was one of the first group therapy programmes developed in the United States. In multiple impact therapy (MIT), families are seen concurrently by a number of multi-disciplinary medical professionals. The duration of the therapy is short, typically ranging from one to two full treatment days.

The focus of treatment is to find and evaluate structural patterns within the family, evaluate those patterns to see if they are the source of the problem, then modify the structure to alleviate the problem.

Background

MIT as a therapy technique was developed at the University of Texas Medical Branch in the 1950s. At the time, Texas had very few psychoanalysts and those that were available were unaffordable to most families. Because treatment was scarce, there were few specialised programmes for adolescents, many were admitted as patients to psychiatric hospitals. Beginning in 1957, parents began bringing their troubled kids to the University of Texas Medical Branch for treatment.

Dr. Robert MacGregor, the lead researcher of group psychotherapy at the University of Texas Medical Branch, began developing MIT by interviewing entire families together in a single session. MacGregor and his team established their main goal as highlighting and emphasizing the parent’s concern to the disturbed child. Between 1957 and 1958, the team saw 12 families as the procedures were being developed. The initial sessions showed that therapy with individual members, together with group sessions, produced the most effective results. The individual sessions gave members the opportunity to voice their personal resentments while the group sessions gave therapists the opportunity to repair poor communication between family members. The therapy’s short, intensive time frame was originally due to life constraints involving time and travel; however, researchers kept the structure because the momentum created in the two day meetings reduced the overall number of sessions needed for the family to improve.

Procedure

MIT may be prescribed to families as a treatment option for a number of reasons: when conventional therapy fails to show results, as an alternative to hospitalisation, as a final course of action before hospitalisation, or for families who were already in group therapy but were seeing few results.

Treatment occurs in approximately seven steps over a two-day period.

Planning

Because many families participating in MIT are unfamiliar with the treatment and with psychotherapy, the planning phase informs the family about what is to be expected over the two days of treatment. Therapists use this time to review current information about the child and interview the community representative (or inpatient staff member) to gather personal details.

Briefing

After the family arrives, the therapy team and family meet for an initial conference to establish why they are gathered there. Intergroup conflict may be high in this phase. Blaming, criticism and aggressive accusations are commonplace. Therapists typically look for signs of defective communication among the family members and make note for later meetings. At the end of this group meeting, each member meets with an individual therapist.

Pressurised Ventilation

In individual meetings with the parents, parents are under a high degree of stress from the full group meeting. Therapists specifically look for the hardships the parents have faced in dealing with their child’s delinquency.

Initial Interview with the Child

The brief initial interview with the child takes place to match family patterns with the child’s behaviour.

Multiple Therapist Situation

After the initial group meet and individual meetings, therapists meet with any member or any number of members together as they see fit. Notes and other data collected (some studies video recorded the group meetings) are used in this procedure to address behavioural patterns and breakdowns in communication. This phase takes up the majority of the first day.

Team-Family Conference

A final group meeting convenes at the end of day one. Family members face each other again for the first time since the initial meeting. The sharing of the revised attitudes the group have towards one another takes place. The shift from conflict in the initial interview to the improved attitudes in the final team conference leads to the creation of a climate of change among the group.

Second Day Procedures

The second day attempts to begin in the same climate that created in the first. Day one often illuminates many of the breakdowns the family has experienced while day two focuses on retention of improved attitudes and application to the family’s unique situation. On day two, logistical considerations are often discussed such as: should the child remain hospitalised, continue schooling, or consider a different method of treatment. A two-month and six month follow up appointment is typically scheduled.

Potential Positive and Negative Outcomes

The use of an interdisciplinary team allows the parents, the child and the group as a whole to be seen from multiple viewpoints and through the lens of professionals with different experience and expertise. A typical interdisciplinary team as used in Macgregor’s studies at the University of Texas consisted of a psychologist, an associate therapist, a social worker, a nurse, and a member of the family’s community or inpatient clinic, however, other researchers have used up to 9 therapists in a single session. By including the community or inpatient staff member in MIT, trust and respect with the child’s parents increases.

Fifty-five additional families were seen between 1958 and 1962 when MacGregor first published his findings on MIT. Within the fifty-five families, only seven were considered unsuccessful cases. Despite the apparent success of MIT, two major drawbacks, the relative efficiency of the programme and conflict between the interdisciplinary team, were noted.

What is Group Psychotherapy?

Introduction

Group psychotherapy, or group therapy, is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including Art therapy, cognitive behavioural therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilised as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.

The broader concept of group therapy can be taken to include any helping process that takes place in a group, including support groups, skills training groups (such as anger management, mindfulness, relaxation training or social skills training), and psychoeducation groups. The differences between psychodynamic groups, activity groups, support groups, problem-solving and psychoeducational groups have been discussed by psychiatrist Charles Montgomery. Other, more specialised forms of group therapy would include non-verbal expressive therapies such as art therapy, dance therapy, or music therapy.

Brief History

The founders of group psychotherapy in the USA were Joseph H. Pratt, Trigant Burrow and Paul Schilder. All three of them were active and working at the East Coast in the first half of the 20th century. In 1932 Jacob L. Moreno presented his work on group psychotherapy to the American Psychiatric Association, and co-authored a monograph on the subject. After World War II, group psychotherapy was further developed by Moreno, Samuel Slavson, Hyman Spotnitz, Irvin Yalom, and Lou Ormont. Yalom’s approach to group therapy has been very influential not only in the USA but across the world.

An early development in group therapy was the T-group or training group (sometimes also referred to as sensitivity-training group, human relations training group or encounter group), a form of group psychotherapy where participants (typically, between eight and 15 people) learn about themselves (and about small group processes in general) through their interaction with each other. They use feedback, problem solving, and role play to gain insights into themselves, others, and groups. It was pioneered in the mid-1940s by Kurt Lewin and Carl Rogers and his colleagues as a method of learning about human behaviour in what became the National Training Laboratories (also known as the NTL Institute) that was created by the Office of Naval Research and the National Education Association in Bethel, Maine, in 1947.

Moreno developed a specific and highly structured form of group therapy known as psychodrama (although the entry on psychodrama claims it is not a form of group therapy). Another recent development in the theory and method of group psychotherapy based on an integration of systems thinking is Yvonne Agazarian’s systems-centred therapy (SCT), which sees groups functioning within the principles of system dynamics. Her method of “functional subgrouping” introduces a method of organizing group communication so it is less likely to react counterproductively to differences. SCT also emphasizes the need to recognise the phases of group development and the defences related to each phase in order to best make sense and influence group dynamics.

In the United Kingdom group psychotherapy initially developed independently, with pioneers S. H. Foulkes and Wilfred Bion using group therapy as an approach to treating combat fatigue in the Second World War. Foulkes and Bion were psychoanalysts and incorporated psychoanalysis into group therapy by recognising that transference can arise not only between group members and the therapist but also among group members. Furthermore, the psychoanalytic concept of the unconscious was extended with a recognition of a group unconscious, in which the unconscious processes of group members could be acted out in the form of irrational processes in group sessions. Foulkes developed the model known as group analysis and the Institute of Group Analysis, while Bion was influential in the development of group therapy at the Tavistock Clinic.

Bion’s approach is comparable to social therapy, first developed in the United States in the late 1970s by Lois Holzman and Fred Newman, which is a group therapy in which practitioners relate to the group, not its individuals, as the fundamental unit of development. The task of the group is to “build the group” rather than focus on problem solving or “fixing” individuals.

In Argentina an independent school of group analysis stemmed from the work and teachings of Swiss-born Argentine psychoanalyst Enrique Pichon-Rivière. This thinker conceived of a group-centred approach which, although not directly influenced by Foulkes’ work, was fully compatible with it.

Therapeutic Principles

Irvin Yalom proposed a number of therapeutic factors (originally termed curative factors but renamed therapeutic factors in the 5th edition of The Theory and Practice of Group Psychotherapy).

  • Universality:
    • The recognition of shared experiences and feelings among group members and that these may be widespread or universal human concerns, serves to remove a group member’s sense of isolation, validate their experiences, and raise self-esteem
  • Altruism:
    • The group is a place where members can help each other, and the experience of being able to give something to another person can lift the member’s self esteem and help develop more adaptive coping styles and interpersonal skills.
  • Instillation of hope:
    • In a mixed group that has members at various stages of development or recovery, a member can be inspired and encouraged by another member who has overcome the problems with which they are still struggling.
  • Imparting information:
    • While this is not strictly speaking a psychotherapeutic process, members often report that it has been very helpful to learn factual information from other members in the group.
    • For example, about their treatment or about access to services.
  • Corrective recapitulation of the primary family experience:
    • Members often unconsciously identify the group therapist and other group members with their own parents and siblings in a process that is a form of transference specific to group psychotherapy.
    • The therapist’s interpretations can help group members gain understanding of the impact of childhood experiences on their personality, and they may learn to avoid unconsciously repeating unhelpful past interactive patterns in present-day relationships.
  • Development of socialising techniques:
    • The group setting provides a safe and supportive environment for members to take risks by extending their repertoire of interpersonal behaviour and improving their social skills
  • Imitative behaviour:
    • One way in which group members can develop social skills is through a modelling process, observing and imitating the therapist and other group members.
    • For example, sharing personal feelings, showing concern, and supporting others.
  • Cohesiveness:
    • It has been suggested that this is the primary therapeutic factor from which all others flow. Humans are herd animals with an instinctive need to belong to groups, and personal development can only take place in an interpersonal context.
    • A cohesive group is one in which all members feel a sense of belonging, acceptance, and validation.
  • Existential factors:
    • Learning that one has to take responsibility for one’s own life and the consequences of one’s decisions.
  • Catharsis:
    • Catharsis is the experience of relief from emotional distress through the free and uninhibited expression of emotion.
    • When members tell their story to a supportive audience, they can obtain relief from chronic feelings of shame and guilt.
  • Interpersonal learning:
    • Group members achieve a greater level of self-awareness through the process of interacting with others in the group, who give feedback on the member’s behaviour and impact on others.
  • Self-understanding:
    • This factor overlaps with interpersonal learning but refers to the achievement of greater levels of insight into the genesis of one’s problems and the unconscious motivations that underlie one’s behaviour.

Settings

Group therapy can form part of the therapeutic milieu of a psychiatric in-patient unit or ambulatory psychiatric partial hospitalisation (also known as day hospital treatment). In addition to classical “talking” therapy, group therapy in an institutional setting can also include group-based expressive therapies such as drama therapy, psychodrama, art therapy, and non-verbal types of therapy such as music therapy and dance/movement therapy.

Group psychotherapy is a key component of milieu therapy in a therapeutic community. The total environment or milieu is regarded as the medium of therapy, all interactions and activities regarded as potentially therapeutic and are subject to exploration and interpretation, and are explored in daily or weekly community meetings. However, interactions between the culture of group psychotherapeutic settings and the more managerial norms of external authorities may create ‘organisational turbulence’ which can critically undermine a group’s ability to maintain a safe yet challenging ‘formative space’. Academics at the University of Oxford studied the inter-organisational dynamics of a national democratic therapeutic community over a period of four years; they found external steering by authorities eroded the community’s therapeutic model, produced a crisis, and led to an intractable conflict which resulted in the community’s closure.

A form of group therapy has been reported to be effective in psychotic adolescents and recovering addicts. Projective psychotherapy uses an outside text such as a novel or motion picture to provide a “stable delusion” for the former cohort and a safe focus for repressed and suppressed emotions or thoughts in the latter. Patient groups read a novel or collectively view a film. They then participate collectively in the discussion of plot, character motivation and author motivation. In the case of films, sound track, cinematography and background are also discussed and processed. Under the guidance of the therapist, defence mechanisms are bypassed by the use of signifiers and semiotic processes. The focus remains on the text rather than on personal issues. It was popularised in the science fiction novel, Red Orc’s Rage.

Group therapy is now often utilised in private practice settings.

Group analysis has become widespread in Europe, and especially the United Kingdom, where it has become the most common form of group psychotherapy. Interest from Australia, the former Soviet Union and the African continent is also growing.

Research on Effectiveness

A 2008 meta-analysis found that individual therapy may be slightly more effective than group therapy initially, but this difference seems to disappears after 6 months. There is clear evidence for the effectiveness of group psychotherapy for depression: a meta-analysis of 48 studies showed an overall effect size of 1.03, which is clinically highly significant. Similarly, a meta-analysis of five studies of group psychotherapy for adult sexual abuse survivors showed moderate to strong effect sizes, and there is also good evidence for effectiveness with chronic traumatic stress in war veterans.

There is less robust evidence of good outcomes for patients with borderline personality disorder, with some studies showing only small to moderate effect sizes. The authors comment that these poor outcomes might reflect a need for additional support for some patients, in addition to the group therapy. This is borne out by the impressive results obtained using mentalisation-based treatment, a model that combines dynamic group psychotherapy with individual psychotherapy and case management.

Most outcome research is carried out using time-limited therapy with diagnostically homogenous groups. However, long-term intensive interactional group psychotherapy assumes diverse and diagnostically heterogeneous group membership, and an open-ended time scale for therapy. Good outcomes have also been demonstrated for this form of group therapy.

Computer-Supported Group Therapy

Research on computer-supported and computer-based interventions has increased significantly since the mid-1990s. For a comprehensive overview of current practices (refer to Computer-supported psychotherapy).

Several feasibility studies examined the impact of computer-, app- and media-support on group interventions. Most investigated interventions implemented short rationales, which usually were based on principles of cognitive behaviour therapy (CBT). Most research focussed on:

  • Anxiety disorders (e.g. social phobia, generalised anxiety disorder).
  • Depression (e.g. mild to moderate Major Depression).
  • Other disorders (e.g. hoarding).

While the evidence base for group therapy is very limited, preliminary research in individual therapy suggests possible increases of treatment efficiency or effectiveness. Further, the use of app- or computer-based monitoring has been investigated several times. Reported advantages of the modern format include improved between-session transfer and patient-therapist-communication, as well as increased treatment transparency and intensity. Negative effects may occur in terms of dissonance due to non-compliance with online tasks, or the constriction of in-session group interaction. Last but not least, group phenomena might influence the motivation to engage with online tasks.

Book: Integrated Group Therapy for Bipolar Disorder and Substance Abuse

Book Title:

Integrated Group Therapy for Bipolar Disorder and Substance Abuse.

Author(s): Roger D. Weiss and Hilary S. Connery.

Year: 2011.

Edition: First (1st).

Publisher: Guildford Press.

Type(s): Paperback and Kindle.

Synopsis:

Packed with practical clinical tools, this book presents an empirically supported treatment expressly designed for clients with both bipolar disorder and substance use disorders. Integrated group therapy teaches essential recovery behaviours and relapse prevention skills that apply to both illnesses.

The volume provides a complete session-by-session overview of the approach, including clear guidelines for setting up and running groups, implementing the cognitive-behavioral treatment techniques, and troubleshooting frequently encountered problems.

In a large-size format for easy reference and photocopying, the book features more than 30 reproducible handouts, forms, and bulletin board materials.