Kaplan + Sadock's Synopsis of Psychiatry, 11e

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28.4 Family Therapy and Couples Therapy

Table 28.4-1 Rationale for Family-Life Chronology

The family therapist enters a session knowing little or nothing about the family. The therapist may know who the identified patient is and what symptoms the patient manifests, but that is usually all. So the therapist must get clues about the meaning of the symptom. The therapist may know that pain exists in the marital relationship, but needs to get clues about how the pain shows itself. The therapist needs to know how the mates have tried to cope with their problems. The therapist may know that the mates both operate from models (from what they saw going on between their own parents), but needs to find out how those models have influenced each mate’s expectations about how to be a mate and how to be a parent. The family therapist enters a session knowing that the family, in fact, has had a history, but that is usually all. Every family, as a group, has gone through or jointly experienced many events. Certain events (e.g., deaths, childbirth, sickness, geographical moves, and job changes) occur in almost all families. Certain events primarily affect the mates and only indirectly the children. (Maybe the children were not born yet or were too young to fully comprehend the nature of an event as it affected their parents. They may have only sensed periods of parental remoteness, distraction, anxiety, or annoyance.) The therapist can profit from answers to just about every question asked. Family members enter therapy with a great deal of fear. Therapist structuring helps decrease the threats. It says, “I am in charge of what will happen here. I will see to it that nothing catastrophic happens here.” All members are covertly feeling to blame that nothing seems to have turned out right (even though they may overtly blame the identified patient or the other mate). Parents, especially, need to feel that they did the best they could as parents. They need to tell the therapist, “This is why I did what I did. This is what happened to me.” A family-life chronology that deals with such facts as names, dates, labeled relationships, and moves, seems to appeal to the family. It asks questions that members can answer, questions that are relatively nonthreatening. It deals with life as the family understands it. Family members enter therapy with a great deal of despair. Therapist structuring helps stimulate hope. As far as family members are concerned, past events are part of them. They now can tell the therapist, “I existed.” And they can also say, “I am not just a big blob of pathology. I succeeded in overcoming many handicaps.” If the family knew what questions needed asking, they would not need to be in therapy. So the therapist does not say, “Tell me what you want to tell me.” Family members will simply tell the therapist what they have been telling themselves for years. The therapist’s questions say, “I know what to ask. I take responsibility for understanding you. We are going to go somewhere.” The family therapist also knows that, to some degree, the family has focused on the identified patient to relieve marital pain. The therapist also knows that, to some degree, the family will resist any effort to change that focus. A family-life chronology is an effective, nonthreatening way to change from an emphasis on the “sick” or “bad” family member to an emphasis on the marital relationship. The family-life chronology serves other useful therapy purposes, such as providing the framework within which a reeducation process can take place. The therapist serves as a model in checking out information or correcting communication techniques and placing questions and eliciting answers to begin the process. In addition, when taking the chronology, the therapist can introduce in a relatively nonfrightening way some of the crucial concepts to induce change.

(Adapted from Satir V. Conjoint Family Therapy . Palo Alto, CA: Science and Behavior; 1967:57, with permission.)

Table 28.4-2 Criteria for Treatment Termination

alliances and splits among family members, hierarchy of power (parents in charge of children), clarity and firmness of bound- aries between the generations, and family tolerance for one another. The structural model uses concurrent individual and family therapy. General Systems Model.  Based on general systems the- ory, a general systems model holds that families are systems and that every action in a family produces a reaction in one or more of its members. Families have external boundaries and internal rules. Every member is presumed to play a role (e.g., spokes- person, persecutor, victim, rescuer, symptom bearer, nurturer), which is relatively stable, but which member fills each role may change. Some families try to scapegoat one member by blam- ing him or her for the family’s problems (the identified patient). If the identified patient improves, another family member may become the scapegoat. The general systems model overlaps with some of the other models presented, particularly the Bowen and structural models.

Treatment is completed: When family members can complete transactions, check, ask When they can interpret hostility When they can see how others see them When they can see how they see themselves When one member can tell others how they manifest themselves When one member can tell others what is hoped, feared, and expected from them When they can disagree When they can make choices When they can learn through practice When they can free themselves from the harmful effects of past models When they can give clear messages—that is, be congruent in their behavior—with a minimum of difference between feelings and communication and with a minimum of hidden messages.

(Adapted from Satir V. Conjoint Family Therapy . Palo Alto, CA: Science and Behavior; 1967:133, with permission.)