clinical psychology

1. FAMILY AND COUPLESFAMILY AND COUPLES
THERAPYTHERAPY
Lecture 36Lecture 36

2. FAMILY THERAPYFAMILY THERAPY
 Family therapy is a form ofFamily therapy is a form of psychotherapypsychotherapy thatthat
involves all the members of a nuclear orinvolves all the members of a nuclear or
extended family.extended family.
 It may be conducted by a pair of therapists—It may be conducted by a pair of therapists—
often a man and a woman—to treat gender-often a man and a woman—to treat gender-
related issues or serve as role models forrelated issues or serve as role models for
family members.family members.

3.  Although some types of family therapy areAlthough some types of family therapy are
based on behavioral or psychodynamicbased on behavioral or psychodynamic
principles, the most widespread form is basedprinciples, the most widespread form is based
on family systems theory, an approach thaton family systems theory, an approach that
regards the entire family as the unit ofregards the entire family as the unit of
treatment, and emphasizes such factors astreatment, and emphasizes such factors as
relationships and communication patternsrelationships and communication patterns
rather than traits or symptoms in individualrather than traits or symptoms in individual
membersmembers
 PURPOSE:-PURPOSE:-
 The purpose of family therapy is to identify andThe purpose of family therapy is to identify and
treat family problems that cause dysfunction.treat family problems that cause dysfunction.

4.  Family therapy is often recommended when:Family therapy is often recommended when:
 A family member has schizophrenia or suffers fromA family member has schizophrenia or suffers from
another severeanother severe psychosis.psychosis.
 Problems cross generational boundaries.Problems cross generational boundaries.
 Families deviate from social norms (unmarriedFamilies deviate from social norms (unmarried
parents, gay couples rearing children, etc.).parents, gay couples rearing children, etc.).
 Members come from mixed racial, cultural, or religiousMembers come from mixed racial, cultural, or religious
backgrounds.backgrounds.
 One member is being scapegoated, or their treatmentOne member is being scapegoated, or their treatment
in individual therapy is being undermined.in individual therapy is being undermined.
 The identified patient's problems seem inextricablyThe identified patient's problems seem inextricably
tied to problems with other family members.tied to problems with other family members.
 A blended (i.e. step) family is having adjustmentA blended (i.e. step) family is having adjustment
difficulties.difficulties.

5.  PRECAUTIONS:-PRECAUTIONS:-
 Before family therapy begins, family members areBefore family therapy begins, family members are
required to undergo a comprehensive clinicalrequired to undergo a comprehensive clinical
evaluation (interview) that includes questions of aevaluation (interview) that includes questions of a
personal and sensitive nature.personal and sensitive nature.
 Honest communication between the family membersHonest communication between the family members
and the therapist is essential; people who are notand the therapist is essential; people who are not
willing to discuss and change behaviors may notwilling to discuss and change behaviors may not
benefit from therapy.benefit from therapy.
 Families that may not be considered suitableFamilies that may not be considered suitable
candidates for family therapy include those in which:candidates for family therapy include those in which:
 One or both parents is psychotic or have beenOne or both parents is psychotic or have been
diagnosed with antisocial or paranoid personalitydiagnosed with antisocial or paranoid personality
disorder.disorder.
 Cultural or religious values are opposed to, orCultural or religious values are opposed to, or
suspicious of, psychotherapy.suspicious of, psychotherapy.

6.  Some family members cannot participate inSome family members cannot participate in
treatment sessions because of illness or othertreatment sessions because of illness or other
physical limitations.physical limitations.
 Individuals have very rigid personalityIndividuals have very rigid personality
structures and might be at risk for an emotionalstructures and might be at risk for an emotional
or psychological crisis.or psychological crisis.
 Members cannot or will not be able to meetMembers cannot or will not be able to meet
regularly for treatment.regularly for treatment.
 The family is unstable or on the verge of break-The family is unstable or on the verge of break-
up.up.
 Intensive family therapy may be difficult forIntensive family therapy may be difficult for
psychotic family members.psychotic family members.

7. DESCRIPTIONDESCRIPTION::
 It began shortly after World War II, when doctors whoIt began shortly after World War II, when doctors who
were treating schizophrenic patients noticed that thewere treating schizophrenic patients noticed that the
patients' families communicated in disturbed ways.patients' families communicated in disturbed ways.
 These observations led to considering a family as anThese observations led to considering a family as an
organism (or system) with its own internal rules,organism (or system) with its own internal rules,
patterns of functioning, and tendency to resist change.patterns of functioning, and tendency to resist change.
 When the therapists began to treat the families asWhen the therapists began to treat the families as
whole units instead of focusing solely on thewhole units instead of focusing solely on the
hospitalized member, they found that in many caseshospitalized member, they found that in many cases
the schizophrenic family member improve.the schizophrenic family member improve.
 Family therapy is becoming an increasingly commonFamily therapy is becoming an increasingly common
form of treatment as changes in American society areform of treatment as changes in American society are
reflected in family structures; it is also helpful when areflected in family structures; it is also helpful when a
child or other family member develops a seriouschild or other family member develops a serious
physical illness.physical illness.

8.  Family therapy tends to be short term, usually severalFamily therapy tends to be short term, usually several
months in length, aimed at resolving specific problemsmonths in length, aimed at resolving specific problems
such as eating disorders, difficulties with school, orsuch as eating disorders, difficulties with school, or
adjustments to bereavement or geographicaladjustments to bereavement or geographical
relocation.relocation.
 It is not normally used for long-term or intensiveIt is not normally used for long-term or intensive
restructuring of severely dysfunctional families.restructuring of severely dysfunctional families.
 In therapy sessions, all members of the family andIn therapy sessions, all members of the family and
both therapists are present.both therapists are present.
 The therapists try to analyze communication andThe therapists try to analyze communication and
interaction between all members of the family.interaction between all members of the family.
 Therapists who work as a team also model newTherapists who work as a team also model new
behaviors through their interactions with each other.behaviors through their interactions with each other.

9.  Family therapy is based on systems theory.Family therapy is based on systems theory.
 Problems are treated by changing the way theProblems are treated by changing the way the
system works rather than trying to "fix" asystem works rather than trying to "fix" a
specific member.specific member.
 Family systems theory is based on severalFamily systems theory is based on several
major concepts:major concepts:
 The identified patient:-The identified patient:-The identified patientThe identified patient
(IP) is the family member with the symptom that(IP) is the family member with the symptom that
has brought the family into treatment.has brought the family into treatment.
 Homeostasis:-Homeostasis:-This concept presumes that theThis concept presumes that the
family system seeks to maintain its customaryfamily system seeks to maintain its customary
organization and functioning over time.organization and functioning over time.

10.  The extended family field:-The extended family field:-The extended family fieldThe extended family field
is the nuclear family plus the network of grandparentsis the nuclear family plus the network of grandparents
and other members of the extended family.and other members of the extended family.
 Differentiation:-Differentiation:-Differentiation refers to each familyDifferentiation refers to each family
member's ability to maintain his or her own sense ofmember's ability to maintain his or her own sense of
self while remaining emotionally connected to theself while remaining emotionally connected to the
family; this is the mark of a healthy family.family; this is the mark of a healthy family.
 Triangular relationships:-Triangular relationships:-Family systems theoryFamily systems theory
maintains that emotional difficulties in families aremaintains that emotional difficulties in families are
usually triangular—whenever any two persons haveusually triangular—whenever any two persons have
problems with each other, they will "triangle in" a thirdproblems with each other, they will "triangle in" a third
member to stabilize their own relationship.member to stabilize their own relationship.

11. POSSIBLE RISKSPOSSIBLE RISKS
 There are no major risks involved in receiving familyThere are no major risks involved in receiving family
therapy, especially if family members seek the therapytherapy, especially if family members seek the therapy
with honesty, openness, and a willingness to change.with honesty, openness, and a willingness to change.
Changes that result from the therapy may be seen byChanges that result from the therapy may be seen by
some as "risks"—the possible unsettling of rigidsome as "risks"—the possible unsettling of rigid
personality defenses in individuals, or the unsettling ofpersonality defenses in individuals, or the unsettling of
couple relationships that had been fragile before thecouple relationships that had been fragile before the
beginning of therapy, for example.beginning of therapy, for example.
NORMAL RESULTSNORMAL RESULTS
 The goal of therapy is the identification and resolutionThe goal of therapy is the identification and resolution
of the problem that is causing the family's unhealthyof the problem that is causing the family's unhealthy
interactions. Results vary, but in good circumstancesinteractions. Results vary, but in good circumstances
they include greater insight, increased differentiationthey include greater insight, increased differentiation
of individual family members, improvedof individual family members, improved
communication within the family, and loosening ofcommunication within the family, and loosening of
previously automatic behavior patterns.previously automatic behavior patterns.

12. VARIETIES OF FAMILYVARIETIES OF FAMILY
THERAPYTHERAPY

13. CONJOINT FAMILY THERAPYCONJOINT FAMILY THERAPY: -: -
In conjoint family therapy,In conjoint family therapy, the entire-family is seen at thethe entire-family is seen at the
same time by one therapist.same time by one therapist.
 In some varieties of this approach, the therapist playsIn some varieties of this approach, the therapist plays
a, rather passive, nondirective role.a, rather passive, nondirective role.
 In other varieties, the therapist is an active force,In other varieties, the therapist is an active force,
directing the conversation, assigning tasks to variousdirecting the conversation, assigning tasks to various
family members, imparting, direct instruction regardingfamily members, imparting, direct instruction regarding
human relationshuman relations,, and, so on.and, so on.
 Satir regarded the family therapist as a resourceSatir regarded the family therapist as a resource
perspersoon who observes the family process in action andn who observes the family process in action and
then becomes a modethen becomes a modell of communication to the familyof communication to the family
through clear, crisp communication.through clear, crisp communication.
 Thus, Satir viewed the therapist as a--teacher, aThus, Satir viewed the therapist as a--teacher, a
resource person, and a communicator.resource person, and a communicator.

14. Concurrent Family Therapy: -Concurrent Family Therapy: -
 InIn concurrent family therapy,concurrent family therapy, one therapist sees allone therapist sees all
family members, but in individual sessions.family members, but in individual sessions.
 In some instances, the therapist may conductIn some instances, the therapist may conduct
traditional psychotherapy with the principal patient buttraditional psychotherapy with the principal patient but
also occasionally see other members of the family.also occasionally see other members of the family.
 As a matter of fact, it is perhaps unfortunate that theAs a matter of fact, it is perhaps unfortunate that the
last variation is not used more often as a part oflast variation is not used more often as a part of
traditional psychotherapy.traditional psychotherapy.
 The use of such arrangements should facilitate theThe use of such arrangements should facilitate the
therapeutic process.therapeutic process.

15. Collaborative Family TherapyCollaborative Family Therapy::
 InIn collaborativecollaborative familyfamily therapy,therapy, each family membereach family member
sees a different therapist.sees a different therapist.
 The therapists then get together to discuss theirThe therapists then get together to discuss their
patients and the family as a whole.patients and the family as a whole.
 The use of this approach with child patients was oneThe use of this approach with child patients was one
of the factors that stimulated the early growth of familyof the factors that stimulated the early growth of family
therapy.therapy.
 In a variation of this general approach, co-therapistsIn a variation of this general approach, co-therapists
are sometimes assigned to work with the same family.are sometimes assigned to work with the same family.

16. Behavioral family therapyBehavioral family therapy::
 A process of inducing family members to dispense theA process of inducing family members to dispense the
appropriate reinforcements to one another for theappropriate reinforcements to one another for the
desired behaviors.desired behaviors.
 Some therapists even have family members useSome therapists even have family members use
tokens for this purpose.tokens for this purpose.
 it is not surprising that this approach has found its wayit is not surprising that this approach has found its way
into the family therapy enterprise.into the family therapy enterprise.
 Similar to cognitive-behavioral therapy for theSimilar to cognitive-behavioral therapy for the
individual, the family "version" involves teachingindividual, the family "version" involves teaching
individual family members to self-monitor problematicindividual family members to self-monitor problematic
behaviors and patterns of thinking, to develop newbehaviors and patterns of thinking, to develop new
skills , and to challenge interpretations of family eventsskills , and to challenge interpretations of family events
and reframe these interpretation if necessary.and reframe these interpretation if necessary.

17. COUPLES THERAPYCOUPLES THERAPY

18. The focus of couples therapy is to identify the presenceThe focus of couples therapy is to identify the presence
of dissatisfaction and distress in the relationship, andof dissatisfaction and distress in the relationship, and
to devise and implement a treatment plan.to devise and implement a treatment plan.
The objectives of treatment are to improve or alleviateThe objectives of treatment are to improve or alleviate
the symptoms and restore the relationship to athe symptoms and restore the relationship to a
healthier level of functioning.healthier level of functioning.
 Also called marital therapy or marriage counseling.Also called marital therapy or marriage counseling.
 It is designed to help intimate partners improve theirIt is designed to help intimate partners improve their
relationship Couples therapy is a form of psychologicalrelationship Couples therapy is a form of psychological
therapy used to treat relationship distress for boththerapy used to treat relationship distress for both
individuals and couples.individuals and couples.

19. PURPOSEPURPOSE
 The purpose of couples therapy is to restore a betterThe purpose of couples therapy is to restore a better
level of functioning in couples who experiencelevel of functioning in couples who experience
relationship distress.relationship distress.
 The reasons for distress can include poorThe reasons for distress can include poor
communication skills, incompatibility, or a broadcommunication skills, incompatibility, or a broad
spectrum of psychological disorders that includespectrum of psychological disorders that include
domestic violence, alcoholism, depression, anxiety,domestic violence, alcoholism, depression, anxiety,
andand schizophreniaschizophrenia..
 The focus is to identify the presence of dissatisfactionThe focus is to identify the presence of dissatisfaction
and distress in the relationship, and to devise andand distress in the relationship, and to devise and
implement a treatment plan with objectives designedimplement a treatment plan with objectives designed
to improve or alleviate the presenting symptoms andto improve or alleviate the presenting symptoms and
restore the relationship to a better and healthier levelrestore the relationship to a better and healthier level
of functioning.of functioning.

20. PRECAUTIONSPRECAUTIONS
 Couples who seek treatment should consult forCouples who seek treatment should consult for
services from a mental health practitioner whoservices from a mental health practitioner who
specializes in this area.specializes in this area.
 Patients should be advised that honesty,Patients should be advised that honesty,
providing all necessary information,providing all necessary information,
cooperation, keeping appointments on time,cooperation, keeping appointments on time,
and a sincere desire for change andand a sincere desire for change and
improvement are all imperative to increase theimprovement are all imperative to increase the
chance of successful outcome.chance of successful outcome.
 Additionally, a willingness to work "towards"Additionally, a willingness to work "towards"
and "with" the process of treatment is essential.and "with" the process of treatment is essential.

21. DESCRIPTIONDESCRIPTION
 Couples therapy sessions differ according toCouples therapy sessions differ according to
the chosen model, or philosophy behind thethe chosen model, or philosophy behind the
therapy.therapy.
 There are several models for treating couplesThere are several models for treating couples
with relationship difficulties. These commonlywith relationship difficulties. These commonly
utilized strategies include:utilized strategies include:
• Psychoanalytic couples therapy,Psychoanalytic couples therapy,
• Object relations couple therapy,Object relations couple therapy,
• Ego analytical couples therapy,Ego analytical couples therapy,
• Behavioral couples therapy,Behavioral couples therapy,
• Integrative behavioral couples therapy, andIntegrative behavioral couples therapy, and
• Cognitive behavioral couples therapy.Cognitive behavioral couples therapy.

22. PSYCHOANALYTICAL COUPLES THERAPYPSYCHOANALYTICAL COUPLES THERAPY
 Psychoanalytic therapy attempts to uncoverPsychoanalytic therapy attempts to uncover
unresolved childhood conflicts with parental figures.unresolved childhood conflicts with parental figures.
 It tends to develop an understanding of interpersonalIt tends to develop an understanding of interpersonal
interactions (at present) in connection with earlyinteractions (at present) in connection with early
development.development.
 The essential core of this model deals with theThe essential core of this model deals with the
process of separation and individuation from mother-process of separation and individuation from mother-
child interactions during childhood.child interactions during childhood.
 A critical part of this model is introjection.A critical part of this model is introjection.
 The psychoanalytic approach analyzes maritalThe psychoanalytic approach analyzes marital
relations and mate selection as originating fromrelations and mate selection as originating from
parent-child relationship during developmental stagesparent-child relationship during developmental stages
of the child.of the child.

23. OBJECT RELATIONS COUPLE THERAPYOBJECT RELATIONS COUPLE THERAPY
 The object relations model creates an environment ofThe object relations model creates an environment of
neutrality and impartiality to understand the distortionsneutrality and impartiality to understand the distortions
and intra-psychic (internalized) conflicts that eachand intra-psychic (internalized) conflicts that each
partner contributes to the relationship in the form ofpartner contributes to the relationship in the form of
dysfunctional behaviors.dysfunctional behaviors.
 This model proposes that there is a complementaryThis model proposes that there is a complementary
personality fit between couples that is unconsciouspersonality fit between couples that is unconscious
and fulfills certain needs.and fulfills certain needs.
 This model supports the thought that a "motheringThis model supports the thought that a "mothering
figure" is the central motivation for selection andfigure" is the central motivation for selection and
attachment of a mate.attachment of a mate.
 Choosing a "mothering" figure induces furtherChoosing a "mothering" figure induces further
repression This repression causes relationshiprepression This repression causes relationship
difficulties.difficulties.

24. EGO ANALYTICAL COUPLES THERAPYEGO ANALYTICAL COUPLES THERAPY
 Ego analytical approaches utilize methods to fosterEgo analytical approaches utilize methods to foster
the ability to communicate important feelings in thethe ability to communicate important feelings in the
couple's relationship.couple's relationship.
 This model proposes that dysfunction originates fromThis model proposes that dysfunction originates from
the patient's incapabilities to recognize intolerancethe patient's incapabilities to recognize intolerance
and invalidation of sensitivities and problems in aand invalidation of sensitivities and problems in a
relationship.relationship.
 There are two major categories of problems:There are two major categories of problems:
1.1. Dysfunction brought into the relationship from earlyDysfunction brought into the relationship from early
childhood trauma and experiences.childhood trauma and experiences.
2.2. The patient's reaction to difficulties and a sense ofThe patient's reaction to difficulties and a sense of
unentitlement .unentitlement .
 A patient's shame and guilt are major factorsA patient's shame and guilt are major factors
precipitating the thoughts of unentitlement.precipitating the thoughts of unentitlement.

25. BEHAVIORAL MARITAL THERAPYBEHAVIORAL MARITAL THERAPY
 Behavioral marital therapists tend to improveBehavioral marital therapists tend to improve
relationships between a couple by increasingrelationships between a couple by increasing
positive exchanges and decreasing thepositive exchanges and decreasing the
frequency of negative and punishingfrequency of negative and punishing
interactions.interactions.
 This model focuses on the influence thatThis model focuses on the influence that
environment has in creating and maintainingenvironment has in creating and maintaining
relationship.relationship.
 The amount of rewards (positive re-inforcers)The amount of rewards (positive re-inforcers)
received in relation to the amount of aversivereceived in relation to the amount of aversive
behavior is linked to an individual's sense ofbehavior is linked to an individual's sense of
relationship dissatisfaction.relationship dissatisfaction.

26. COGNITIVE BEHAVIORAL COUPLESCOGNITIVE BEHAVIORAL COUPLES
THERAPYTHERAPY
 The cognitive approach therapist educates andThe cognitive approach therapist educates and
increases awareness concerning perceptions,increases awareness concerning perceptions,
assumptions, attributions or standards of interactionassumptions, attributions or standards of interaction
between the couple.between the couple.
 The central theme for understanding marital discourseThe central theme for understanding marital discourse
using cognitive behavioral therapy is based on theusing cognitive behavioral therapy is based on the
behavioral marital therapy model.behavioral marital therapy model.
 A couple's emotional and behavioral dysfunctions areA couple's emotional and behavioral dysfunctions are
related to inappropriate information processing, andrelated to inappropriate information processing, and
negative cognitive appraisals.negative cognitive appraisals.
 This models attempts to discover the negative types ofThis models attempts to discover the negative types of
thinking that drive negative behaviors that causethinking that drive negative behaviors that cause
relationship distressrelationship distress

27. Follow UpFollow Up
 Treatment usually takes several months or longer.Treatment usually takes several months or longer.
 Once the couple has developed adequate skills andOnce the couple has developed adequate skills and
has displayed an improved level of functioning that ishas displayed an improved level of functioning that is
satisfactory to both, then treatment can be terminated.satisfactory to both, then treatment can be terminated.
 An awareness of relapse prevention behaviors andAn awareness of relapse prevention behaviors and
relapsing behaviors is important.relapsing behaviors is important.
 Patients are encouraged to return to treatment ifPatients are encouraged to return to treatment if
relapse symptoms appear.relapse symptoms appear.
 Follow-up visits and long-term psychological therapyFollow-up visits and long-term psychological therapy
can be arranged between parties if this is mutuallycan be arranged between parties if this is mutually
decided as necessarydecided as necessary

28. POSITIVE RESULTSPOSITIVE RESULTS
 A normal progression of couple’s therapy is relief fromA normal progression of couple’s therapy is relief from
symptomatic behaviors that cause marital discourse,symptomatic behaviors that cause marital discourse,
distress, and difficulties.distress, and difficulties.
 The couple is restored to healthier interactions andThe couple is restored to healthier interactions and
behaviors are adjusted to produce a happier balancebehaviors are adjusted to produce a happier balance
of mutually appropriate interactions.of mutually appropriate interactions.
 Patients who are sincere and reasonable with aPatients who are sincere and reasonable with a
willingness to change tend to produce betterwillingness to change tend to produce better
outcomes. Patients usually develop skills andoutcomes. Patients usually develop skills and
increased awareness that promotes healthierincreased awareness that promotes healthier
relationship interactions.relationship interactions.

29. RISK FACTORSRISK FACTORS
 The major risk of couples therapy is lack ofThe major risk of couples therapy is lack of
improvement or return to dysfunctional behaviors.improvement or return to dysfunctional behaviors.
 These tend not to occur unless there is a breakdownThese tend not to occur unless there is a breakdown
in skills learned and developed during treatment, or ain skills learned and developed during treatment, or a
person is resistant to long-term change.person is resistant to long-term change.
LimitationsLimitations
 There are no known abnormal results from couplesThere are no known abnormal results from couples
therapy.therapy.
 At worst, patients do not get better.At worst, patients do not get better.
 The problems are not worsened if treatment isThe problems are not worsened if treatment is
provided by a trained mental health practitioner in thisprovided by a trained mental health practitioner in this
specialty.specialty.