Download - Dr. krishnan's family therapy
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Introduction to Family Therapy
Dr. S. KrishnanAssociate Professor of PsychiatryGovernment Medical College, Thiruvananthapuram
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Before you start…
You are an outsider You don’t have a right to intrude and peep You are not a savior or judge Don’t promise to solve all the family
issues Beware of transference issues Family is different from HOME
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Family Therapy
An intervention which focuses on altering the interactions among family members and improve the functioning of the family as a unit of individual members of the family
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Birth of Family Therapy
Numerous phenomena gave rise to family therapy and the systems perspective in the 1940s & 1950s Small group dynamics Marriage Counseling Research on schizophrenia The Child Guidance Movement
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Indications
Precipitating
Perpetuating
Maintaining
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Therapist’s Task
Identify family’s unspoken rules
Disagreements about who makes these rules
Distorted ways of communications in the family
Rigid intergenerational patterns which cause distress within or between individuals
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Of use in…
Child psychiatric problems Adolescent crises Schizophrenia Bipolar disorders Dissociative disorders Somatoform disorders Dysthymia Recurrent depressive disorders And many more…
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Role of therapist
Understand the rules
Modify the rules
Improve communicat
ion
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How many sessions
5-10 sessions (Milan Approach) at intervals of 1 month or more
2-3 sessions when the patient is in the hospital (preferably no more than one session per week)
Each session of 1-3 hours duration Duration of therapy depends on the model
used: Problem solving models (short duration) Growth oriented models ) (long durations -
years)
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How many Family Members?
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How many Therapists?
1
2
35
10
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Goals…
Improved communication
Improved autonomy for each member
Improved agreement about roles
Reduced conflict
Reduced distress in the index client
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Family Cycle
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Families in Distress…
All families face two types of stressors
Developmental stressors
Environmental stressors
Families in distress are not sick, but have been unable to adjust to the stressors
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Developmental Stressors
Marriage 1st child in family 1st teenager in
family Gender role
changes Death of a parent Children leave
home
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Environmental Stressors
Fire Injury War New job or job
loss Financial
stressor Rape
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A Distressed Family
Is often unwilling to take responsibility Interprets problems from a linear
causality perspective, rather than a circular perspective.
Suffers a confusion of levels (children and parents)
Forms coalitions (a parent and a child against another parent)
Appoints children to quasi-adult roles (a child taking on the role of one parent’s confidant)
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Why families enter therapy?
Stressors -- environmental and developmental -- arise in the normal course of a family’s life.
The failure of its members to cope with and accommodate to stressors leads members to disengage from some members, and become enmeshed with others
Indirectness of communication and anxiety ensues, with triangular relationships substituting for direct encounter and the pursuit of intimacy.
Identified client is usually reason for entering therapy, but often only the symptom of family distress..
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Triangular Relationship
Concept by Murray Bowen Two-person relationship is the basic unit of
any emotional system. Under stress the two-person system tends to
draw in a third person to stabilize ( three-person system of two-against-one).
When anxiety builds up in any one triangle, it spills over into other triangles, filling the whole family system.
Problematic behavior patterns
Monica McGoldrick, Genograms. W.W.Norton, 2007
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Triangular Relationship
Families repeat themselves. What happens in one generation will
often repeat itself in the next, though the actual behavior may take a variety of forms.
Monica McGoldrick, Genograms. W.W.Norton, 2007
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Rules Matter
Families have rules that determine how balance is reinstated. If something violates the rules, then one of two things happen: Members reassert the
rules. The family changes the
rules.
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Values Matter
Families have values that assign meaning to various events. It is important to understand those values in working with families.
Values are a function of family and cultural origins.
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Language Matters
Families have ways of describing people and situations that reflect their values and rules.
It is important to understand the way the family uses language, in order to effectively reframe people and situations whenever a more positive viewpoint is possible.
Reframing is using language to describe a person or a situation in a more positive way.
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Models of Family therapy
Psychodynamic-experiential models Bowen model – family systems
model Structural model
General systems model
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Bowen Family Systems Theory:Basic Constructs
Murray Bowen The family is an emotional
system composed of many generations, whether living or dead.
The goal of therapy is the differentiation of self from one’s family-of-origin.
Individuals who are not differentiated form unstable relationships and are prone to triangulation.
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Bowen Family Systems Theory:Therapeutic Techniques
The goal of therapy is differentiation. Focus on family and relationship
patterns rather than specific issues. Look for signs of emotional cut-off and
triangles. The stance of the therapist is that of observer.
Therapists must be highly differentiated to avoid the emotionality of the family system.
Genograms help clients map multigenerational processes.
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Systems Approach to Family Therapy
Salvador Minuchin General systems approach to family
therapy Focused on the balance between
stability & change, openness & closedness.
Its efficacy has been demonstrated with a wide variety of family configurations.
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First major influence on family systems theory…
Observations made of the communication styles in schizophrenic families.
Double bind Marital schism Marital skew Pseudomutual and
pseudohostile communication
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Double Bind
A view that when an individual receives an important message with two different meanings and is unable to respond to it, the individual is in an impossible situation.
If such messages are repeated over time, individuals may begin to show signs of schizophrenia.
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Marital Schism
A situation in which one parent tries to undermine the worth of another (parent) by competing for sympathy or support from the children.
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Marital Skew
A situation in which the psychological disturbance of one parent dominates the family’s interactions.
An unreal situation for family members is created so that the family can deal with one member’s disturbance.
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Pseudomutuality
Presenting an appearance of open relationships in a family so as to conceal distant or troubled relationships within the family.
Members develop roles that they play rather than relating honestly.
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General Systems Theory
A system represents a set of units that stand in some consistent relationship to one another.
A system is organized around relationships.
Elements (units) interact with each other in a predictable, “organized” fashion.
Units, once combined form an entity - a whole, greater than the sum of its parts.
Therefore, no element can be understood in isolation.
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General Systems Theory
The organization of relationships may include groups, alliances, coalitions, and tensions.
The organization gives clues to the system’s consistent or repetitive interactive patterns…know as rules.
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Family Rules
Family rules: Family interactions follow certain
persistent patterns – rules (Jackson, 1965) Redundancy principle – a family interacts
in repetitive behavioral sequences. Rules may be▪ Descriptive - metaphors describing patterns of
interaction.▪ Prescriptive – directing what can or cannot
occur between members.
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General Systems Theory
How changes in one family member can bring about changes in another, by looking at the entire family as a unit.
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General Systems Theory
Feedback: the reinsertion into a system of the results of its past performance, as a method of controlling the system.
Negative feedback: Information that flows back to a system to reduce behavior that causes disequilibrium.
Positive feedback: Information that leads to deviation from the system’s norm, bringing about change and a loss of stability.
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General Systems Theory
Equifinality: the ability of a system to arrive at the same destination from different paths.
Homeostasis: A dynamic state of balance or equilibrium in a system, or a tendency toward achieving and maintaining such a state in an effort to ensure a stable environment.
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A step-by-step approach
to Family Therapy…
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Prerequisite
Assessment of the family structure Summarizing family structure –
GENOGRAM (Murray Bowen) Current and past state of family life Roles of the members Therapist tries to answer two
questions: How the family functions Whether family factors are involved in
client’s problems
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Initial Phase
1) Inviting entire family to session 2) Joining and building a collaborative
relationship 3) Assessing problem from multiple
perspectives 4) Assessing family rules, values, language
patterns, and goals (teleological lens) 5) Assessing cultural issues (multicultural
lens), and family of origin for patterns across the generations (developmental lens) genogram
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Interventions
6) Observing, or tracking interactional patterns -- asking process questions (Bowen) educates the family about circular causality I-position encourages taking responsibility
and ending of blame 7) Observing and encouraging typical dynamics
-- enactments (Minuchin). Therapist may use Reframing, poking, “stroke and a kick” Assigning tasks▪ boundary adjustments▪ eliciting and supporting competencies
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Circular Questioning
One person is asked to comment on the relationships of others.
Others are asked to comment on her response
Purpose is to discover and clarify confusing and conflicting views
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Paradoxical injunctions
Designed to provoke the family into making changes which they cannot make in other ways
Paradoxical injunctions are impossible or counter intuitive suggestions which force the family to confront their hidden or unacceptable motives
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How does the family function?
Structure (genogram) (single parent, step parent, size and age of spread of he sibship)
Relationships (close, distant, uncooperative, conflictual)
Patterns of interactions (child siding with one parent against the other)
Changes and events (births, deaths, departures, financial problems
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Genogram
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Genogram
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Genogram
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Genogram
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Genogram
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Are family factors involved in client’s problems?
Contribute to patient’s problems (son does not want to leave widowed mother after marriage)
Supporting the client (codependence)
Reacting to the client’s problems (unrelated other problems may be there)
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Cognitive Distortions
Denial Distortions Arbitrary inferences Selective abstraction Overgeneralization Minimization Maximization Dichotomous thinking Personalization…
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Restructuring Concepts
Supporting parents (hierarchies) Insulating parents from their own families
of origins Insulating parents from children Establishing direct communication or “De-
triangulating” Nurturing competencies through reframing
symptoms as strengths and assigning tasks
Redefining relationships one-to-one with family of origin
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Typical Problems
Critical/Enmeshed Parent / In-Law
Acting out Teenager
Affairs
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Critical/Enmeshed Parent / In-Law
Unwillingness of adult child to assert boundaries
Unwillingness of son/daughter in-law to confront parent directly
Can lead to carryover of anger of adult child to spouseEstablish better boundaries and privacy between couple and parentConfront in-law by adult childEstablish direct relationship between son/daughter in-law and parent in-law (de-triangulation)
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Acting out Teenager
Usually one parent is disengaged from the family
The other parent is usually over-involved in the “problem” child’s life.
There is a lack of intimacy between couple due to preoccupation with child.
There is often a neglect of other children’s needs
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Acting out Teenager
Get couple to work together to resolve differences, clarify rules, and express expectations
Reframe teenager’s behavior if possible
Encourage direct communication between teenager and disengaged parent(s) without interference
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Affairs
Usually occurs during major developmental or environmental stressors, which disrupt communication and intimacy between spouses
Can be due to lifelong suppression of one’s needs in the context of a marital relationship
Can be due to lack of intimacy due to family pressures
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Affairs
Establish that it takes two for an affair to happen.
Need to communicate unspoken needs perhaps too much difference or
“complementarity” perhaps not enough “similarity,” and
quality time explore unexpressed dreams
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Tools for all seasons
Focus on process (how) rather than content (what)
Focus on interpersonal dynamics, rather than personal feelings and thoughts
Focus on here and now, vs. there and then
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Tools for All Seasons
Teach Circular Causality/Reciprocity Ask “process questions” that encourage
linking one’s own behavior to the effects on others, example: “What effect does it have on her when you withdraw and watch TV?” or “Have you tried to talk with him about it rather than giving him the silent treatment?”
Encouraging I-position, not talking about others
Explore cross-generational patterns
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Tools for All Seasons
De-triangulating▪ Getting people to talk directly without interruptions▪ Role playing direct communication▪ Having everyone present for meeting
Acknowledging competencies and putting them to work
Reframing -- “Stroke and Kick” -- Reframe and redirect
Genograms for cross-generational patterns
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Analyse Transactions
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Criteria for Treatment Termination When FMs can complete transactions When FMs can interpret hostility When FMs can see how others see them When FMs can see how they see themselves When one member can tell others what is
hoped, feared and expected from them or how they manifest themselves
When FMs can disagree When FMs can make choices When FMs can learn through practice When FMs can free themselves from harmful
effects of past models When FMs can give clear message
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Modifications of Techniques
Family group therapy
Social network therapy
Paradoxical therapy
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Thanks a Lot