Systems of Psychotherapy: A Transtheoretical Analysis

1. Systems of Psychotherapy:A Transtheoretical Analysis Chapter 12. Systemic Therapies

2. The Context of Systemic Therapies • We can only be understood within social context; contextless is meaninglessness • Patient is the entire system, not the identified patient (IP) • General Systems Theory & cybernetics are the intellectual inspirations for systems tx • Systems = parts of an organization + relationships among those parts

3. 2 Meanings of Systemic Therapies • Therapy modality or format (like indiv therapy and couple therapy) • Treatment content or goal (what is discussed or intended)

4. Four Systemic Therapies • Communication/strategic therapy • Structural therapy • Bowenian therapy • Evidence-based family therapy

5. Communication/StrategicTherapy • Mental Research Institute (MRI) & Double Bind Communications Project • Key figures: Jay Haley, John Weakland, Donald Jackson, Virginia Satir • Communication key to understanding behavior • Assume that all behavior is communication • Classic example: double bind • Interventions change communication

6. Theory of Psychopathology • Psychopathology is a function of unclear or hostile communication • Pathology is family’s homeostatic mechanism to maintain system balance • Pathology occurs when rules of relating become ambiguous • Unclear communication patterns make rules ambiguous

7. 5 Axioms of Communication • It is impossible to not communicate • Communication implies commitment & defines relationships (report & command) • Relationships are contingent on how a communication is punctuated or ended • Communication is both verbal & nonverbal • Communications are symmetrical (either leads) or complementary (one side leads)

8. Therapeutic Processes • Help systems to communicate clearly & constructively • Emphasis on how people communicate rather than what they communicate about • Changing communication changes relationships & power dynamics

9. Processes of Change • Consciousness raising: aware of rules for communicating & relating, reframing • Choosing: straight directives & paradoxical techniques • Catharsis: Satir’s emphasis on feelings • Counterconditioning: Haley’s emphasis on power & ordeal therapy

10. Therapeutic Relationship • Develop an atmosphere conducive to congruent & functional communication • Empathy & positive regard important • Therapist is in charge & in control • Therapist uses direct and indirect techniques to control relationship

11. Practicalities of Communication/Strategic • 1- to 1½-hour sessions • Better if whole family is present but can work with the couple subsystem • Sessions often videotaped • One-way mirrors frequently used • Insurance billing forces identification of one patient for reimbursement

12. Effectiveness of Communication/Strategic • Not a lot of controlled outcome studies or formal research on effectiveness • Few existing evaluations yield statistically and clinically nonsignificant effects • Effective in treating substance abuse • Uncertain effectiveness in other disorders

13. Structural Therapy • Founded by Salvador Minuchin (1921-2017) • Created to treat delinquents as systemic issue rather then individual problem • Initial focus on delinquency, asthma, & anorexia nervosa • Influential and pragmatic approach

14. Structural Theory of Psychopathology • More concerned with what maintains psychopathology than with its causes • Historical causes cannot be empirically determined & cannot be changed • Dysfunctional structure of family system maintain psychopathology

15. Boundaries • An organized family has clear boundaries • Disengaged families have rigid boundaries (little contact between family members) • Enmeshed families have diffuse boundaries (tight interlocking/enmeshment) • Dysfunctional families respond to demands for change in pathological ways

16. Structural Therapeutic Processes • Goal: restructure families to free members to grow & relate • Changing family structure entails changing the system’s boundaries • Consciousness raising: education, reframing • Choosing or social liberation: create more alternatives for healthy responding

17. Therapeutic Relationship • Therapist joins each member or sub-system of family to overthrow existing rules • Involves empathy, warmth, and caring • Once relationship established, therapist becomes authoritative leader • Therapist challenges, blocks, & disrupts homeostasis

18. Practicalities of Structural Therapy • Active, short-term treatment • Format follows function of therapy, usually conjoint sessions • Restructure seating as a function of restructuring family • Booster sessions are natural and economical • Pioneers in videotaping and live supervision

19. Effectiveness of Structural Therapy • Reliance on clinical case surveys • Few controlled studies • Found superior to no treatment & probably superior to indiv tx for substance abuse, psychosomatic disorder, & conduct disorder • Untested in treatment of most disorders

20. Bowen Family Systems Therapy • Developed by Murray Bowen (1913 – 1990) • Initially applied to schizophrenic patients and their families at NIMH • Dramatically applied to his own family • A cerebral & deliberate approach

21. Bowen’s Theory of Psychopathology • Differentiation of self is ability to think objectively & control emotions • Pathology arises from not differentiating from families of origin (fusion) • Fusion results in undifferentiated family ego mass • Fusion leads to triangulation

22. Bowen’s Theory of Psychopathology (cont.) • The child closest to parents is most likely to develop pathological symptoms • Emotional cutoffs are efforts to cope with unresolved attachments to families of origin • Family projection process • Multi-generational transmission process

23. Therapeutic Processes • Goal: increase differentiation of self from family emotional system • Detriangulate family members • Change produced in one triad will probably cause change in all family triangles • Consciousness raising: observation of communication, education • Choosing: responding autonomously

24. Therapeutic Relationship • Therapists do not get triangulated • Maintain an objective “I” position • Therapists model autonomous, responsible, & differentiated behavior • Therapists relate in a calm, relaxed, and genuine manner • Therapists rely on observation & reason (not empathy) to understand family

25. Practicalities of Bowen Family System Therapy • Often work with spouses or with one parent • Central couple is most important • Strong proponent of family of origin therapy for psychotherapists • Active, short-term treatments that initiate the change process • Highly compatible with time-limited psychotherapy

26. Effectiveness of Bowen Family Systems Therapy • Lack of RCTs on effectiveness • Few studies have been open, uncontrolled trials • Effectiveness has been largely untested

27. Evidence-Based Family Therapies New generation of empirically tested family therapies: • Functional family therapy • Multidimensional family therapy • Multisystemic therapy (MST)

28. Multisystemic Family Therapy • Typically for youth with conduct disorders and substance abuse • Multiple targets of treatment: individual, family, and larger system • Goal is to break cycle of antisocial activities • Therapists often visit homes & schedule frequent sessions • Intensive therapy approach

29. 5 P’s for Resuming Contact 1. Prepare 2. Persevere 3. Practice “Foot in the Door” technique 4. Provide positive reinforcement 5. Promote urgency

30. Therapeutic Processes of MST • Consciousness raising • Choosing • Counterconditioning • Contingency management

31. Therapeutic Relationship • Youth, family, and entire system are recipients of services • Devoted to systemic change • MST therapists are on call 24/7 & work with limited number of families • Construct multiple collaborations, rather than the therapeutic alliance

32. Effectiveness of MST • Effective & cost-effective in treatment of conduct disorders • Demonstrates long-term effectiveness for juvenile offenders & their families • Effective to include parents in treatment • No convincing evidence MST outperforms other systemic therapies • Not suited for all patients and contexts

33. Effectiveness of Couple Therapy • Marriage and relationship education yield small to medium effects on relationship quality & communication skills • Couple therapies typically effective (and under-utilizied) for many “individual” disorders • Gottman approach seems promising but awaits controlled trials on its effectiveness

34. Effectiveness of Systemic Therapies • 20+ meta-analyses show couple & family therapies are effective; average ES = .65 • Positive effects remain but taper over time • No difference in effectiveness among different systemic therapies • No consistent outcome differences between individual & family therapy; “for now, a tie”

35. Effectiveness of Family Therapy as Tx Format • Particularly effective in motivating substance abusers to enter treatment • Significantly lower drug use after family treatment compared to non-family therapy • Family treatment of schizophrenia reduces relapse & improves outcome • Outperforms no treatment and TAU for youth with conduct problems

36. Criticisms of Systemic Therapies • From a Psychoanalytic Perspective (lacks consideration of individual, history of pathology cannot be ignored) • From a Cognitive-Behavioral Perspective (too similar to psychoanalytic therapy, lack of controlled research) • From a Humanistic Perspective (therapist may be causing resistance and is too powerful) • From a Cultural Perspective (masculine, white, traditional bias, not inclusive) • From an Integrative Perspective (not every problem is a systems problem)

37. Future Directions • Systems theory is moving mainstream • Promising direction in conjoint therapy for individual disorders • Applications beyond the nuclear family: family medicine, addictions, organizations • Inclusion of diagnoses for relational functioning • Future lies in integration & cultural competence

38. Key Terms accommodation boundaries Bowenian/family systems therapy communication therapies complementary relationship cybernetics differentiation of self directives disengaged family double bind communication emotional cutoff enactments enmeshed family evidence-based family therapies expressed emotion (EE) family of origin therapy family projection process fusion General Systems Theory (GST) Genogram Gottman Approach homeostasis identified patient (IP) joining metachange metacommunication mimesis multigenerational transmission process

39. Key Terms (cont.) Multisystemic Therapy (MST) nonlinear dynamics open systems ordeal therapy paradoxical directives/techniques power prescribing the symptom punctuation reductio ad absurdum reframing relabeling “responsible I” social liberation straight directives strategy/strategic therapy structure structural therapy surrender tactic symmetrical relationship system systemic therapy therapeutic double binds therapy modality/format triangles/triangulation undifferentiated family ego mass

40. Recommended Websites • Ackerman Institute for the Family: www.ackerman.org/ • American Association for Marriage and Family Therapy: aamft.org • Avanta—Virginia Satir Network: www.satirglobal.org/ • Bowen Center for the Study of the Family: www.thebowencenter.org/index.html • Minunchin Center for the Family: www.minuchincenter.org • Multisystemic Therapy: www.mstservices.com/ • The Gottman Institute: www.gottman.com/