The development of practice called ‘family therapy’ began about 60 years ago and represented a significant paradigm shift in counselling and psychotherapy. Instead of a focus on individual pathology, its focus was on ‘the space between’ people (connections, patterns, processes) in families. The relationship became the client, rather than the individuals within the work. Attention for therapy became the here-and-now rather than the past, and the patterns and behaviours which promote and sustain symptoms and problems, and which impede the family’s own ability to find creative solutions and draw on their own inherent strengths. It was often said that “information is the difference that makes the difference”, with an emphasis on active, creative interviewing that could engage all participants, elicit the unsaid, and enable change to take place.
Intuitively, this always made sense. We live our lives through relationships, and when relationships go seriously wrong, emotionally and psychologically, there can be dramatic effects. Systemic therapists approach distress by looking at ways that relationships can be adapted or engaged to assist. Even where there is a biological basis for the issue at hand, or an event that has come into play, or a reaction to a change in developmental stage, relationship problems have a real effect on the level of distress, likelihood of relapse, the significance of change, and the compliance with intervention (Stratton, 2016). Often the most difficult or even bizarre behaviour makes sense when seen in its relational context.
The practice of family therapy looks very different now, although the core principles remain. Previously a provocative challenger of the mental health establishment, celebrating an alternative approach to health care intervention, family therapy now involves methods that coordinate and integrate other methods of treatment, and has developed into evidence based treatment for many complex problems, combining “cutting edge science while embracing the complexity and artfulness of clinical implementation of those models” (Lebow & Sexton, 2016, p. 1).
Tenets of family therapy
Structure
The family is a social system which supports the survival, stability and welfare of its members. It is more than the sum of its parts; each person’s position needs to be understood, but there is also the group dynamic of the whole. The boundary around the family sets it apart from the wider social and cultural system, of which it is one sub-system. However, understanding how the systems (extended family, school, work, church, cultural group) interlock and intersect also assist in understanding why individuals act the way that they do. Ideally boundaries are semi-permeable, allowing information and resources to enter and leave the family (Carr, 2016).
Process and behaviour
The behaviour and response of each family member, and their engagement in the wider systems around them, makes sense when viewed in light of all other responses within the system, and needs to be understood in this wider context. People are inextricably linked in their interactional patterns. For example, if the family contains a secret – such as violence, alcoholism or gambling – individually and collectively they may seem isolated and disengaged from their social systems. A child in a classroom may seem lonely, remote or depressed.
Family roles, routines, rituals are all illustrations of the way a family functions. The value of flexibility, responsiveness and cohesion are seen to enhance family experience. Triangulation, collusion and negative polarisations such as demand/withdraw, dominance/submission, pursuit/distance have been articulated as some of the dynamics which could bring the family unstuck (Carr, 2016).
Within families there are processes that promote or prevent change. The question for therapy is what gets in the way of moving in the direction that they themselves know they need to go? The principle of equifinality is important here – different paths can lead to the same outcomes. There is no right way to achieve a goal, but rather more or less effective ways.
“The family therapist takes a position of respect and curiosity, conceptualising the problems from a starting point that the family is doing the best it can, even if the behaviours seem to be redundant or unhelpful”
Conceptualising problems
Family therapy theory broke with the tradition of linear causality (A causes B), which dominates in the medical model. For example, thinking that a child’s behaviour is the result of parental mismanagement. Instead, the way in which the children and parents reciprocally interact is considered. It could be that a parent is so overwhelmed by child management and guilt at their own ineffectiveness that they are inconsistent in their messaging; and that the child is quite understandably acting out in a quest to be both connected and contained.
An understanding of behavioural reciprocity, feedback loops and recursive cycles of interaction was well-articulated in the early years of family therapy, and terms such as ‘virtuous’ and ‘vicious’ cycles of interaction illustrated those that might work for or against a good family experience.
Symptomatic behaviour of one family member may result in them being defined as the ‘identified patient’. However, the symptom may be able to be understood as achieving family homeostasis (Carr, 2016). For example, parents may be on the cusp of announcing their separation to their children. However, a child has considerable school difficulty and it is advised that the parents work together to assist her, resulting in the parents holding back their announcement.
This is not a conscious plot by any member, and in fact is most likely to be operating on quite an unconscious level. Hence this is described as the effect of the symptom, that is that the effect of the child’s struggle is to slow down the pace of separation and remind the parents of the need to work together for their children, rather than something like: the parents can’t separate because their child needs them, or even more negative, that the child is attention-seeking!
Role of the therapist
The family therapist takes a position of respect and curiosity, conceptualising the problems from a starting point that the family is doing the best it can, even if the behaviours seem to be redundant or unhelpful. A facilitator of a better conversation between family members, the therapist does not take a position of expert, but coaches the family to determine preferred ways of being, developing plans for change and ways to pool family resources to create momentum. A key assumption is that the family does have some past successes that, when illuminated, can be used to progress change.
The evidence base
Empirical studies and metaanalyses of family therapy, either alone or part of multimodal programs, have demonstrated its efficacy for a very wide range of presenting problems. For adults, these include relationship distress, psychosexual problems, anxiety and mood disorders, intimate partner violence, alcohol problems, schizophrenia and adjustment to chronic illness or injury. For children these include sleep, feeding and attachment problems in infancy, child abuse and neglect, conduct problems, emotional problems (such as grief, anxiety, depression, self-harm and bipolar disorder), eating disorders and somatic problems (enuresis, encopresis, medically unexplained symptoms, and poorly controlled asthma and diabetes, and first-episode psychosis).
The results are often dramatic, with studies suggesting that the average family fares better after treatment and at 6–12 month follow-up than 71 per cent of families in control groups. It also shows reduced use of health services, involves fewer sessions and has greater benefits than individually based treatments (Carr, 2014).
Again, intuitively this makes sense. How many of us have worked week after week with someone who is conflict avoidant while they carefully plot the right thing to say and the right day and time to say it? In a session with a family, inevitably someone lets a cat or two out of various bags, and then the work is underway. I am reminded of a session where the three-year-old answered the questions most directly. I asked who is best at arguing in the family, and she loudly announced, “Mum and Dad”. In a skilfully managed family meeting, the work occurs in situ, and when they leave together, there is potentially a critical mass of enthusiasm to create change, a momentum that can be sustained in response to the ambivalence, caution or reticence that an individual might take longer to address alone.
Metaanalyses of family therapy outcomes describe a variety of interventions, including parent-based training, family meetings for the purposes of psychoeducation, support groups for family members, and so on. Indeed, many psychologists might describe themselves as ‘seeing families’, when they are undertaking traditional individual work, with say a child, and informing the parents at the end of the session as to what they can do for follow-up. This is valuable, as the more people involved, the greater the potential for other family members to have their attention drawn to new aspects of behaviour, such as positives and strengths, and to give them something different to do, such as admire rather than worry. However, more fully embracing the foundational underpinnings of systemic practice offers so many more resources to draw from, including the family’s own collective ideas and wisdom about what works for them.
Exploring with curiosity
When working more closely with one family member, it is tempting to drift into blame of those in their lives, and when that person is a child, to become critical of the parenting. I have discussed many such moments with supervisees, who see an anxious parent verbally taking over the session as ‘intrusive’ or ‘controlling’ or ‘demanding’ without enquiry. All it might take is to ask the young person, “how well is mum doing at describing the issues?” to find out that perhaps they agreed beforehand that she would lay-out the scene initially, or that she has such difficulty getting a conversation going at home that she is bursting with ideas that never get a hearing anywhere else.
I recall a colleague commenting on a parent finding it very stressful sitting in the waiting room while seeing a child for play therapy. “Why can’t the mother let the child (aged 6) have their own space?” I invited him to consider what it must be like for a parent to have someone else get to know your child, to get to the bottom of things you feel you can’t resolve yourself (like a ‘good parent’ would). Ultimately, it is for the parent and child to connect, not the therapist and child. Indeed, perhaps the parent is sitting there upset that the child’s dad isn’t there to worry with her or keep her company.
So many possibilities that come from the curiosity and non-pathologising, which are the core tenets of the practice of family therapy, where the task is to make sense of behaviour (that in some way does make sense), not to pathologise and medicalise.
I have also encountered children in the corridor of my practice, creeping up the passageway from the waiting room and pressing their ears against doors, unable to stay where asked because they are worried about what is being said. While having time with different family members can be essential, for example when ascertaining whether there is family or domestic violence, in other ways separating members works against the way they live, love and muddle along together. However messy, argumentative or difficult the session, that is the way the family operates, and separating them to make the work more manageable, or to try and divide and conquer, immediately takes away something that perhaps the family should be struggling with together, with the therapist not as controller and expert, but facilitator and coach.
Considerations for psychologists working with families
Competence: Is generalist training sufficient to undertake complex relational work? The Australian Association of Family Therapy would say no, but this is an unregulated area of work. Establishing legitimacy and ensuring quality with good supervision is critical.
Intake and engagement: Communication with the family needs care and consideration. Is planning with one parent sufficient? What do we gain (in practical terms) and what might we miss in engagement terms? I have asked children what they knew about coming to the session and had them say “Dad said get in the car and you’ll find out when you get there!”
Coercion: Inevitably some people will be at the session because they were coerced. Children attend at their parent’s behest (although I have worked with families where the parents attended at their children’s behest). One parent may be reluctant.
Informed consent: We need to modify our protocols to be able to meet the standard for consent in relation to youngsters and the elderly, and for those with different language and ability. This may need to be repeated as different people attend over time and new matters need to be raised.
Who owns the file: How do you develop the protocols for establishing an effective file, and decide who owns it and has rights over it? This can be determined according to how the case is conceptualised and constructed. That is, whether it is a family file, or a child-focused file with family sessions.
Effective rapport and agenda setting: It is not going to be possible to be equally connected to every person in the family at all times. In any one session, some might get more from it than others. What is required is multi-directed partiality, or more simply, the ability to show appropriate partiality to all members in some way. It means though that your rapport with the family overall, a total of connection to greater and lesser degrees, should be strong enough to keep the motivation up to attend. Different members will also have different reasons to be there, and even setting an agenda can seem like a political act. Managing authoritatively, respectfully and inclusively can be complicated.
Confidentiality and privacy: Some see this as a bit of a nightmare, as the pull to take one side over another, or in separate sessions the risk of being told ‘secrets’ is heightened. How or whether secrets can be managed and in what way you set up protocols regarding disclosure, is essential to think through before undertaking this work. Many have tripped themselves up with promises they can’t keep, or ended up in collusive arrangements with clients, holding information that could be seen to be a betrayal of others in the group. Working within the out-of-home-care or family law areas will also give rise to different case management protocols and communication pathways.
Inclusive practice: Despite the multicultural and open-minded nature of Australia, most of our training is too mainstream. We must ensure that we do not take a position of white privilege and assume our own assessment of being non-judgemental will be sufficient. Working across the family life span means that we can encounter different fashions regarding parenting practices, be challenged by issues such as teens exploring polyamory, donors wanting to be included in the work of same-sex-headed families, elders being the primary carers and so on. We need to be constantly alert and engaged in varied training and supervision and peer experiences to remain nimble yet wise in our clinical judgements and decisions.
Managing other stakeholders: We may have extended family members, foster carers, schools, hospitals and juvenile justice workers who also knock at the door of the therapy room. The family therapist needs to see the work from a multi-system perspective and develop transparent protocols that flex to the circumstances and family needs.
Working within the medical discourse: Many providing services under the Better Access program feel compromised in family work. If they are seeing the family in service of treating the child and want to see the parents alone, there may be no financial support to do so, unless the parents also apply for a mental health care plan, involving a doctor’s referral, separate file and so on, when the (potentially single) session only relates to the child and the parents would not meet eligibility requirements. Better Access has a diagnostic approach, which is also at odds with a strengths based, relational construction of problems. This requires careful consideration and navigation so that one might retain therapeutic fidelity and at the same time attend to one’s duty to meet the terms of service provision under the Better Access program.
Challenges in family work
Australia has developed a rich tradition of family therapy since the 1980s, with key training centres in every state and territory, and private and public health services as well as larger not-for-profit organisations, such as Relationships Australia, funded to provide services. However, in recent times family therapy has languished a little in several ways. Firstly, there are fewer people willing to train to see families. Families scare clinicians it seems, and fewer will pick this area of work as an area of expertise.
Certainly, with more people to contend with, and working with particular life stages such as adolescence, there is a lot to consider. It requires significant training, and after building a career in psychology, perhaps fewer can or want to invest in a graduate diploma or master’s degree in family therapy that is required for clinical accreditation as a family therapist.
Further, until recently, working with families has not been in funding fashion for many years. At a state level, there has been interest in and financial backing of two evidence-based approaches: Functional Family Therapy and Multi-Systemic Therapy. Both derive from systemic foundations, have been manualised and have a significant evidence-base with high-risk populations. Given the cost of out-of-home care, as well as the issues associated with providing such services, these specific approaches hold great appeal with funders, with good reason.
Providing family therapy is arguably ethically more challenging than individual intervention, and our individually based models of ethical decision-making can fall short in helping us reflect and act (Shaw, 2016). I have written about this in more detail elsewhere (Shaw, 2011; 2015).
Family therapy is vibrant, exciting, and varied work. The pace can be faster and the change more pervasive. It takes training, good support and a community of practice to support it, so as not to default to our individually based traditions. The evolution of the core approaches into evidence based practice is very encouraging and of course only confirms work many of us have done well before some of the data-driven imperatives took hold. As with all therapies, we need to be mindful of what the evidence tells us are effective core components, while not losing site of the broader theoretical traditions that contextualise the stepped approaches that are currently underway.
The author can be contacted at [email protected]