Family Therapy Review: Contrasting Contemporary Models

Anne Rambo, Charles West, AnnaLynn Schooley, Tommie V. Boyd

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136243417
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This unique text uses one common case to demonstrate the applications of a wide range of family therapy models. Readers will find it useful when studying for the national family therapy licensing exam, which requires that exam takers be able to apply these models to case vignettes. The authors, all of whom are practicing family therapists, apply their chosen model of family therapy to a single, hypothetical case to highlight what each model looks like in practice. Beginning therapists will find the exposure to new ideas about therapy useful, and will be better able to establish which approaches they want to explore in more depth. Experienced therapists and supervisors will find it useful to understand what "those other family therapists" are doing, and to meet the challenge of supervising those from different perspectives. Family Therapy Review is the practical tool therapists need to make sense of the field, and meet the varied challenges their clients present.

Section II

FAMILY THERAPY MODELS

PART A

PSYCHOANALYTIC/EXPERIENTIAL MODELS

7

A BRIEF HISTORY OF PSYCHOANALYTIC/EXPERIENTIAL MODELS

Anne Rambo, Charles West, AnnaLynn Schooley and Tommie V. Boyd

This section discusses case studies from the psychoanalytic (Chapter 8), symbolic/experiential (Chapter 9), and human validation process (also often called experiential) (Chapter 10) traditions. We have chosen to group these models of family therapy together because, in our view, they share a focus on patterns of emotion. Congruence of affect and expressed emotion, emotional authenticity, and the emotional bond between therapist and client are important in all three of these models.

Psychoanalytic therapy, originated by Freud, is not in itself a systemic model. Yet there are systemic models of family therapy that focus on process and awareness in a way that resonates with this tradition. Nathan Ackerman, one of the founders of family therapy, was himself a practicing psychoanalyst and never gave up on the idea that family therapy could be combined with psychoanalysis, if the family itself were seen as a living system (Ackerman, 1958). Some psychoanalytic family therapy is still practiced at the Ackerman Institute for the Family in New York City, although this is no longer a primary focus (www.ackerman.org). Object relations family therapy is closely related, with a stronger focus on attachment theory, and the International Psychotherapy Institute (www.theipi.org) is a center of training and therapy in the object relations tradition, which includes family therapy among other modalities. Therapists outside the United States often do not see a sharp distinction between psychoanalytic approaches and systemic approaches; the history of family therapy in Europe and Australia was not marked by the outright rejection of psychoanalysis that was a feature of the early history of family therapy in the United States (Ng, 2003). We have chosen to present a blending of psychoanalytic and systemic ideas by Carmel Flaskas from Australia (Chapter 8).

We have chosen as well to group in this section as experiential two other models that are also focused on patterns of authenticity and congruence in emotional expression. These are the symbolic-experiential approach, associated with Carl Whitaker (Chapter 9), and Virginia Satir’s human validation process model (Chapter 9). Both were developed initially in the 1960s. Whitaker’s approach is difficult to replicate, except through intense cotherapy training. Augustus Napier, a trusted colleague of Whitaker’s, now trains in this approach in Atlanta, Georgia, through the Family Workshop center (www.psychotherapy.net/interview/augustus-napier.html).

Satir’s approach, meanwhile, has given birth to an entire international organization, the Avanta Network, dedicated to providing experiential workshops and trainings in her model (www.avanta.net). Satir’s approach is clearly more educational and directive than Whitaker’s, and both Whitaker’s and Satir’s are more deliberately experiential, focused in the present moment, than psychoanalytically informed family therapy. Yet all three of these models have a concern with process, with stimulating the authentic expression of emotion, and with growth rather than behavior change alone, which to us makes them worthy of joint consideration.

Considerations of managed care have made a practice in any of these models somewhat difficult in the United States, as long-term, insight-oriented models are less likely to be reimbursed by insurance. In Europe and Australia, however, these models continue to be quite influential. Their focus on self of the therapist in the moment makes them unique in their approach to training and supervision as well.

References

Ackerman, N. (1958). The psychodynamics of family life. New York, NY: Basic Books.

Ng, K.S. (2003). Global perspectives in family therapy: Development, practice, trends. New York, NY: Routledge.

Additional Resources

Bumberry, W., & Whitaker, C. (1988). Dancing with the family: A symbolic-experiential approach. New York, NY: Routledge.

Flaskas, C. (2002). Family therapy beyond postmodernism: Practice, challenges, theory. New York NY: Routledge.

Gerson, M. (2009). The imbedded self: An integrative psychodynamic and systemic perspective on couples and family therapy. New York, NY: Routledge.

Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir Model: Family therapy and beyond. Palo Alto, CA: Science and Behavior Books.

8

A SYSTEMIC PRACTICE INFLUENCED BY SELECTED PSYCHOANALYTIC IDEAS

Carmel Flaskas

This chapter does not present a “pure” approach and serves instead as an example of a systemic practice influenced by selected psychoanalytic ideas. What do I mean by a systemic practice, and exactly which psychoanalytic ideas do I draw from? The systemic tradition of family therapy has an enduring and central interest in context and relationship, which shapes how the presenting problem is understood and how the therapy itself is undertaken. The orientation to context and relationship marks the continuity from the first generation through to the contemporary approaches. Alongside systemic ideas, which by their very nature all privilege the relational and interpersonal, I draw on some ideas from psychoanalysis that function as a “double description” in my practice. A summary list (Flaskas, 2002) would include the following: the unconscious and unconscious communication; transference, countertransference, projection, and projective identification; containment and the therapeutic “holding frame”; and knowledge about attachment and attachment patterns, allied as much with systemic as psychoanalytic therapy. Psychoanalytic ideas are most regularly in my mind with respect to the therapeutic relationship and my use of self.

The intake notes for this family consist of a bare one paragraph. I don’t know the referral route, and for the purposes of this chapter we’ll assume the family has contacted a government-funded child and adolescent counseling service. I will invite Mary, Fred, and Johnny to attend the first session. My inclination in child and adolescent work is to invite just the immediate family to the first session unless there are some good reasons to do otherwise (for example, cultural family forms or safety priorities around abuse). Though I note the information about the closeness of Mary’s mother, Bess, to Mary and the family, I would not invite Bess to this first meeting. As yet, I have no information about how Bess’s support for Mary is experienced by Fred and Johnny, or indeed who might be the least happy if I were to invite her to the first session.

Working from my systemic understandings, I walk into the first meeting with some relational and contextual hypotheses in my head. The process of hypothesizing in earlier Milan therapy (in the 1980s) was framed within positivist language: hypotheses were to be “tested” within session. But, even then, hypothesizing was seen as a tentative process, and the testing was not about whether a hypothesis was true or false, but instead about whether it was useful in opening out possibilities of change and whether it fit the family’s situation. Systemic hypotheses frame the integrity of the presenting problem: how does the problem potentially make sense relationally and contextually? This practice theory still guides me in 2012, though now I am just as happy for initial hypotheses to stay in the form of interrelated questions rather than more organized scenarios, and to be lightly held in mind rather than tested.

From the intake notes, the presenting problem is around Johnny hating school, skipping class, possibly engaging in high-risk behaviors, and the anxiety and dilemmas for his parents. Mary has headaches she sees as related to this stress. Hypothesizing around developmental issues is a good starting point. And so I would wonder about family challenges when an only child (a son) turns 15 in a threeperson, two-parent (heterosexual couple) family. Is Johnny engaged in the struggle of adolescent autonomy, trying to strike a balance of separating while staying connected to his parents? On the one hand, he could be making a bid for separation in skipping school and hanging out with who he wants while simultaneously inviting his parents to stay heavily involved in his life by alarming them with the dangers. From the parents’ side of the challenge, I wonder about loss and anxiety associated with change. What might it mean to Mary for her son to be most definitely not a child anymore? Has Bess moved in closer to support Mary as she has become more worried and stressed? Is Johnny giving Bess a good reason to move in closer to support Mary? If Bess and Mary have become closer, what effect has this had on Mary and Fred’s relationship (as a couple and as parents)? Or what might Fred’s reactions as a father be to his son’s growing up? What was his own time as an adolescent son like, and how might unworded thoughts/feelings be playing into the stance he is taking with Johnny? Could Johnny’s behavior be allowing Fred to butch up with anger and hide his vulnerabilities? And while I am on this roll, I wonder about the forms of attachment and belonging, and the patterns of balancing intimacy and holding on to self, in Fred’s and Mary’s families’ histories, and in earlier times in their family when Johnny was younger.

Another set of possibilities is sparked by a question in response to the intake notes: why exactly does Johnny hate school? Is he finding the academic work harder now? Does he feel bad about himself and ashamed? Does he fear disappointing his parents, and would he rather exit stage right from school altogether, with face-saving involvement with the group he has fallen in with—sparking the attendant relational fallout sequences in his family? Or has he been bullied or assaulted at school, too humiliated to talk to his parents about it, fearful of his mother’s/father’s distress or anger, and would rather handle it by exiting stage right from school?

So I meet the family. Culturally and in a gendered way I am low key and friendly and have cultivated as a therapist a calm presence (which is not to say I am always calm!), and I use quite a lot of smiling and humor where it seems to fit. There are many different authentic ways to relate therapeutically, and I use what I can of my self in inviting a therapeutic relationship with the family, which I hope will serve as a holding frame for the challenges of the work ahead. I begin with the usual nonproblem talk introductions and from the start take responsibility for introducing a pattern within the therapy of inviting equal airspace and relating consistently in how I respond to the contributions of all three family members. Mary may want me to understand how worrying it is and may hope I can bring Fred around from his punitive reactions; Fred may be pretty lukewarm about the idea of therapy, polite but quite guarded/prickly about how I will respond; Johnny may want to show/tell me it’s all a huge fucking waste of time and nothing to do with him anyway. As I invite each person in turn to tell me what they would like to come from today and what is on their mind most in coming to this counseling meeting, I convey that I am interested, that I want to hear and understand, and I ask questions assuming there will be complete good sense in what each person might choose to say. When I reflect back (which I do fairly sparingly), I phrase it as a form of checking and note the sense of the position from that person’s point of view. In these reflections, I name strengths in a factual rather than complimentary way. At the end of this first part of the meeting, I note differences between the three of them clearly and calmly (conveying without words that there is nothing unusual about the level of differences). If Johnny isn’t talking to me, I come up with two different things he might plausibly have said to me if he felt it was the right time and give his hypothetical contributions the same air space, relating to them in strictly the same way as I relate to his parents’ ideas.

I tend to go slow with introductions and what people want from coming. Very often, I ask the family to tell me about a difficult recent time. Old-fashioned though it may be, a slow working-through of who does what to whom when where and why, inquiring about the meaning and emotion and not just behavior, has a lot of clinical mileage. I will ask the family about the immediate sequence between the three of them, and then the next level out, to each of them: who outside the three of you comes to know about this? If the only answer is Bess, and she is described as being there via and for Mary, I ask who outside the three of them understands most about what it is like for Fred and Johnny? I will ask other-oriented questions in this part of the interview, providing that everyone’s anger and anxiety is contained enough to allow it: So, Mary, when Fred hits the roof when Johnny comes home drunk at 4 a.m., what do you think is really getting to him most as a father? (This would perhaps be followed by: Knowing your husband as well as you do, why do you think this is the thing about what Johnny is doing that gets to him the most?) I will use triadic questions around changes in closeness/distance at significant points in the timeline of the development of the problem—Fred, how have you noticed things change between Johnny and Mary, and between Johnny and you, since the start of Year 9? And, Johnny, since the start of Year 9 and all the arguing, what have you noticed about how things have changed between your parents? (If Johnny still is not into talking, I might begin: I don’t know, Johnny, if you’d want to give your ideas about this or not, but I’ve been sitting here wondering what you’ve noticed.) You can hear that these questions explore relationships held against context, and otheroriented and triadic questions invite different people to voice their understanding of other people and patterns. I would also be checking process to see if the questions and the discussions that emerge are (or are not) having the effect of containing anger and anxiety, opening up a more reflective rather than reactive space, and nurturing a more empathic and compassionate space rather than a blaming-counterblaming space.

I would follow the different stories that emerge from the naming of what needs to be changed, the discussion of sequences, the family’s ideas about each person’s meaning and spot, the relational changes since the beginning of the problem, and what sense they each make of the context of the problem. I would hold these stories against my earlier hypotheses, moving flexibly to other possible understandings that seem a better fit with what the family is telling me now, still drawing these understandings relationally and contextually and respecting the sense of each person’s position while not denying the actual or potential damage/danger. I will take a 5–10 minute break after about 50 minutes, think about what the family has said, then give some feedback. I will start by noting strengths of different members of the family and of the family as a whole, then retell what I have heard about the advent of the problem and different people’...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Introduction: About This Book
• The Common Case and Questions
• SECTION I. About the Field of Family Therapy
• SECTION II. Family Therapy Models
• SECTION III. Couples Therapy, Separately Considered
• SECTION IV. Applications
• Index