Case Vignette

The Bean family was referred to family therapy at the request of the individual therapist for Pam Bean (not her real name), a high school junior who had been losing weight over the past year and had become amenorrheic for the last 6 months. During the year of her weight loss, her older sister, Ellen, had left for college. When asked about other changes in the family, Mrs. Bean, a 45-year-old schoolteacher, stated that her brother’s teenage son had committed suicide the year before. Mr. Bean, a 47-year-old software engineer, added that he had recently taken a new job that necessitated a great deal of travel. Mrs. Bean noted that Pam had been a cheerful child who could be counted on to make others laugh; however, over the last year she had become both withdrawn and moody. Mr. Bean’s relationship with Pam had been close until she reached puberty, but now he felt clueless about how to communicate with her. To make matters more complicated, Mr. Bean’s sister had committed suicide when she was a teenager, and while they were alone together during their parents’ travels. Mr. Bean had always felt responsible for his sister’s suicide. Pam’s sister, Ellen, a 19-year-old college freshman, was about 30 pounds overweight and she worried that Pam might die.

The Theory

This therapy is derived from principles of object relations and Freudian theory. The goal for psychodynamic family therapy, as with individual psychodynamic therapy, is more self-awareness, which is created by bringing unconscious material into conscious thought. At the heart of this practice is the notion that current family problems are due to unresolved issues with the previous generation. Interpersonal function is distorted by attachments to past figures and by the handing down of secrets from one generation to the next. The psychodynamically oriented family therapist wants to free the family from excessive attachment to the previous generation and wants to help family members disclose secrets and express concomitant feelings (e.g., of anger or grief). Change is created through insight that is often revealed in one individual at a time, in a serial fashion, as others look on.

The Practice

In order to loosen the grip of the past on the present, the therapist uses several tools (including interpretation of transferential objects in the room, interpretation of projective identification, and the use of the genogram to make sense of generational transmission of issues). In family therapy, transferential interpretations are made among family members, rather than between the patient and the therapist, as occurs in individual therapy. For example, when Mr. Bean says “I guess I am not an expert when it comes to female problems,” the therapist may have asked, “Who made you feel that way in your family of origin?” When he reveals that he has felt this way since his sister’s suicide, he comes to understand how an old lens distorts his current vision (i.e., he still feels so guilty about his sister’s death that he does not feel entitled to weigh in with opinions about his daughter’s anorexia).

Another important tool for dredging up the past is the interpretation of projective identification, which Zinner and Shapiro² have defined as the process “by which members split off disavowed or cherished aspects of themselves and project them onto others within the family group.” This process generates intrapsychic peace at the expense of interpersonal conflict. For example, Mrs. Bean may disown her need to control her impulses by projecting her perfectionism onto Pam. Simultaneously, Pam can disown her anger by enraging her parents with her anorexia. As these unconscious projections occur reflexively, they are more difficult for the individual to recognize and to own. Put another way, each family member behaves in such a way as to elicit the very part of the self that has been disavowed and projected onto another family member. The purpose of these mutual projections is to keep old relationships alive by the reenactment of conflicts that parents had with their families of origin. Thus, when Mrs. Bean projects her perfectionism onto Pam, she re-creates the conflict she had with her own mother, who lacked tolerance of impulses that were not tightly controlled.

In part, the psychodynamic family therapist gathers and analyzes multigenerational transmission of issues through the use of a genogram (Figure 13-1), a visual representation of a family that maps at least three generations of that family’s history. The genogram reveals patterns (of similarity and difference) across generations—and between the two sides of the family involving many domains: parent-child and sibling roles, symptomatic behavior, triadic patterns, developmental milestones, repetitive stressors, and cutoffs of family members.²

Figure 13-1 The Bean family, October 2006.

In addition, the genogram allows the clinician to look for any resonance between a current developmental issue and a similar one in a previous generation. This intersection of past with present anxiety may heighten the meaning and valence of a current problem.³ With the Bean family (including two adolescents), the developmental imperative is to work on separation; this is complicated by the catastrophic separations of previous adolescents. Their therapist might discover a multigenerational pattern of role reversals, where children nurture parents, as suggested by the repetition of failed attempts of adolescents to separate from their parents.

The Proponents

James Framo⁴ invites parents and adult siblings to come to an adult child’s session; this tactic allows the past to be revisited in the present. This “family of origin” work is usually brief and intensive, and consists of two lengthy sessions on 2 consecutive days. The meetings may focus on unresolved issues or on disclosure of secrets; it allows the adult child to become less reactive to his or her parents.

Norman Paul⁵ believes that most current symptoms in a family can be connected to a previous loss that has been insufficiently mourned. In family therapy, each member mourns an important loss while other members bear witness and consequently develop new stores of empathy.

Ivan Boszormenyi-Nagy⁶ introduced the idea of the “family ledger,” a multigenerational accounting system of obligations incurred and debts repaid over time. Symptoms are understood in terms of an individual’s making sacrifices in his or her own life in order to repay an injustice from a previous generation.

Murray Bowen⁷ stressed the dual importance of the individual’s differentiation of self, while maintaining a connection to the family. In order to promote increased independence, Bowen coached patients to return to their family of origin and to resist the pull of triangulated relationships, by insisting that interactions remain dyadic.

The Metaphor

This therapist is like a lead-testing scientist who tests for levels of lead in one’s garden to assess the legacy of toxins from previous homeowners. Only when the true condition of the soil has been revealed is the current homeowner free to make decisions about whether the soil is clean enough to plant root vegetables; somewhat contaminated, so that only fruit-bearing bushes will be safe; or so toxic that only flowers can be grown without hauling in truckloads of clean, fresh soil. Examination of the past enables the current gardener, and, by analogy, parents, to make informed choices about how the current environment needs to be adjusted and what kind of growth is allowable.

The Theory

In contrast to the psychodynamic family therapist’s focus on the past, the experiential therapist is primarily concerned with the here and now. In this model, change occurs through growth experiences that arise in the therapy session; experiences are aimed at the disruption of familiar interactions among family members. The experiential family therapist tries to make something surprising and unexpected happen, thereby amplifying affect. In general, the expression of feeling is valued over the discovery of insight. In its embrace of experience, this model is atheoretical and it can best be understood in light of its practice.

The Practice

The experiential family therapist is interested in small interactions that take place during the session. For example, the therapist might ask Pam, “Who told you about the meeting today, and what was said?” This therapist might also ask each family member, “What would you wish for right now, here today, that would make your life better?” The therapist would hope to amplify any communication that conveyed warmth and closeness and would interrupt any antagonistic communication. He or she might ask Mrs. Bean to look her husband in the eye, to hold his hand, and to ask for his help in dealing with Pam’s anorexia.

This therapist uses psychodramatic, or action-oriented, techniques to create a new experience in the therapy session. She or he might “sculpt” the family, literally posing them to demonstrate the way that the family is currently organized—for example, with mother and Pam sitting very close together, with Mr. Bean with his back to them, and with Ellen outside of the circle. This therapist would hope to heighten feelings of frustration and alienation, and then to relieve those feelings with a new sculpture that places the parents together. These sculptures would serve to increase affect, to create some focus away from the identified patient, and to demonstrate the merits of the parents who are standing together to combat their daughter’s anorexia.

The Proponents

Virginia Satir,⁸ an early luminary in family therapy (a field that was largely founded by men), believed that good communication depends on each family member feeling self-confident and valued. She focused on what was positive in a family, and used nonverbal communication to improve connections within a family. If families learned to see, to hear, and to touch more, they would have more resources available to solve problems. She is credited with the use of family sculpting as a means to demonstrate the constraining rules and roles in a family.

Carl Whitaker⁹ posited that most experience occurs outside of awareness; he practiced “therapy of the absurd,” a method that accesses the unconscious by using humor, boredom, free association, metaphors, and even wrestling on the floor. Symbolic, nonverbal growth experiences followed, with an aim toward the disruption of rigid patterns of thought and behavior. As Whitaker puts it, “psychotherapy of the absurd can be a deliberate effort to break the old patterns of thought and behavior. At one point, we called this tactic the creation of process koans” (p. 11)⁹; it is a process that stirs up anxiety in family members.

The Metaphor

This type of therapist is like a folk artist who takes commonplace objects and transforms them into works of art. The viewer is surprised to find that a box of mismatched buttons could become the wings of a butterfly. Making the unfamiliar out of the familiar, and using playful techniques to do so, are key features of experiential family therapy.

The Theory

The structural family therapist focuses on the structural properties of the family, rather than on affect or insight. Structure is defined by several features: by the rules of the family (e.g., what subjects can be discussed at the dinner table? What kind of affect is acceptable to express?); by boundaries within the family (e.g., do the children stay clear of marital conflict? Do siblings have their own relationship?); by boundaries between the family and the outside world (e.g., do parents easily request help from outsiders, or are they insulated?); and by the generational hierarchy (e.g., who [the parents, the adolescent, or the grandparents] is in charge of decision-making?). In this model, change occurs when the structure shifts and when symptoms are no longer needed.

This therapist approaches a family with a blueprint of what a normal family should look like, with some allowance made for cultural, ethnic, and economic variations. Most broadly stated, a high-functioning family should have well-defined parental, marital, and sibling subsystems; clear generational boundaries (with the parents firmly in charge); and flexible relationships with outsiders. The family with an eating-disordered member would be expected to have four structural fault lines: first, to be enmeshed (with little privacy and blurred boundaries between the generations so that children may be parenting parents); second, to be excessively overprotective (so that attempts by the children at autonomy are thwarted); third, to be rigid in the face of change (so that any stressor may overwhelm the family’s resources); and fourth, to be relatively intolerant of individual differences (so that the family’s threshold is low for individuals who voice an unpopular or maverick position).

The Practice

This therapist joins the Bean family by supporting the existing rules of the family and by making a relationship with each member. These individual relationships may later be used to restructure the system, for example, by empowering the parents. The therapist, assessing the formal properties of the family, would earmark the shaky alliance between the parents and the lack of well-defined marital, parental, and sibling subsystems. The boundaries within the family are judged as enmeshed, with members talking about each other’s feelings rather than about their own. Between the family and the outside world, the boundaries are rigid, since the Beans have not asked for any help from extended family or school personnel. This family therapist describes the family as involved in a pattern of conflict avoidance called triangulation, with each parent wanting Pam to take his or her side, putting her into an impossible loyalty-bind.

As assessment becomes treatment, this therapist might challenge enmeshment by imposing a rule about communication, whereby each member should speak only for herself or himself. The therapist would try to challenge the lack of a generational hierarchy by manipulating space. For example, the therapist might ask Mr. and Mrs. Bean to sit side-by-side while also instructing Pam and Ellen to leave the room for part of the interview. To challenge the rule that conflict should be avoided, particularly regarding disagreements about how to get Pam to eat, this therapist would have the couple sit together and create a plan for the next meal while the therapist blocks any attempt to involve Pam. The family might then role-play a family meal (in a session) to illustrate Pam’s role in their power struggle. Additionally, Pam and Ellen could be invited to have their own meeting to explore and to shore up their relationship.

The Proponents

Salvador Minuchin,^10,11 regarded as the founding father of structural family therapy, worked extensively while head of the Philadelphia Child Guidance Clinic with inner-city families and with families who faced delinquency and multiple somatic symptoms. Both populations had not previously been treated with family therapy. He delineated how to assess and to understand the existing structure of a family, and pioneered techniques such as the imposition of rules of communication, manipulation of space, and use of enactments to modify structure.

The Metaphor

This therapist is like a building inspector who renders an opinion about the stability of a structure and guides the owner to decisions regarding a large-scale renovation or merely a cosmetic touch-up. The inspector does not care about either the furnishings or the paint colors, but is concerned with whether the walls are solid, the locks are in working order, and the wiring is functional and safe. Everything else follows smoothly if the house is solidly built.

The Theory

The strategic family therapist believes that change occurs when maladaptive behavioral sequences are interrupted. This therapist differentiates between two kinds of change: “first order,” in which commonsense solutions to initial difficulties actually become unsolvable problems; and “second order,” where random events or therapeutic interventions disrupt first-order solutions. These therapists view families as fundamentally homeostatic, or invested in maintaining the status quo even at the expense of a symptomatic family member. Consequently, this therapist anticipates a power struggle between him or her and the family and develops strategies to destabilize the power structure in the family. One such strategy involves the use of paradox, which is used to meet the family isomorphically at the time when they present for therapy. In essence, the position taken by the family is, “Help us get rid of the symptom, but don’t make us change.”

The Practice

The therapist inquires about the behavioral sequences that occur around the family’s problem to understand the first-order solutions that the family has devised, solutions that themselves have become problems. The therapist is interested in the behaviors that occur when Mr. and Mrs. Bean attempt to get Pam to eat. For example, if Mr. Bean says to Pam, “Do you want to eat your sandwich?” and she says “No,” he tries to reason with her. At this point, Mrs. Bean might interrupt and say, “Just eat,” which annoys Mr. Bean, who says, “Let her finish eating on her own timetable.” He adds, “Perhaps there is something you’d prefer to a sandwich.” When Pam doesn’t seem to respond, Mrs. Bean says, “Your not eating is just killing me.” Pam responds by stating, “I won’t eat even if you force the food down my throat.” The strategic therapist notes that the more Mrs. Bean threatens, the more Pam protests; the more she protests, the more Mr. Bean tries to appease. But when he appeases, Pam still doesn’t eat, and Mrs. Bean escalates her argument. Each parent feels that he or she is offering a logical solution: Mrs. Bean is insisting that Pam eat, and Mr. Bean is trying to leave the eating up to Pam. Both are first-order changes that leave Pam in an intolerable bind—to choose one parent over another.

This therapist, then, wants to introduce second-order change, by use of a paradoxical strategy (e.g., prescribing a symptom that is aimed at disrupting the current behavioral sequence). For example, the therapist could suggest, “Pam, I’d like you to resist your parents’ efforts to get you to eat in order to prevent your premature compliance to parental authority.” In being asked not to eat, she finds that her anorexia takes on new meaning and she is taken out of the bind of having to choose between her parents. This is a therapeutic double-bind, that is, an intervention that mirrors the paradoxical communication in the family.

The Proponents

Milton Erikson¹² (whose focus on behavioral change relied on indirect suggestion through the use of stories, riddles, and metaphors) has heavily influenced this school. Strategic therapists have borrowed this reliance on playful storytelling techniques. The California Mental Research Institute (MRI) family therapists, including Jay Haley, Paul Wazlawick, John Weakland, and Gregory Bateson, were the earliest proponents of strategic family therapy. They encouraged therapists to look to the role of power in the therapeutic encounter, since families usually make paradoxical requests, for example, “Get us out of this mess but don’t make us change.”

Chloe Madanes¹³ assumed that when children act out, their symptoms represent efforts to help the family. However, along with helping the family, the child’s symptoms also reverse the generational hierarchy, placing the child in a position that is superior to that of his or her parents. Consequently, Madanes advocated using paradoxical techniques to reassert the parents’ authority. For example, she might invite the parent to ask the child to pretend to help out or to pretend to have the problem. In both instances, these strategies put the parents back in charge, while allowing the child a playful means of being helpful.

The Metaphor

The strategic family therapist is like a master chess player who knows from the start how he or she wants the game to turn out, and then maps out each move to get there. This therapist has a plan for each individual session and a vision for the outcome of this problem-focused therapy. In chess, as in therapy, there is a belief that a small move will set off reverberations throughout the game. This cascade of changes can similarly be planned and mapped out by the therapist.

The Theory

The systemic family therapist believes that change occurs when beliefs are changed or the meaning of behavior is altered. In this view, the solutions, as well as the power to change, lie within the family. This therapist rejects the notion that the therapist holds a clear idea of what the family should look like at the end of successful treatment. The therapist does not presume to know the right truth to help a family. Instead, this therapist holds that there is no one truth; rather, some ideas are more useful than others.

The systemic therapist believes that the family is not homeostatic but instead is constantly evolving. The therapist identifies the place of “stuckness” that is marked by redundant interactional sequences, and introduces new information to the family without a plan for the family’s response. This process is like seeing a mobile that has stopped moving in the wind, then pushing on it, and stepping back to watch (with surprise) how the pieces will resume movement. Movement takes place in leaps rather than in the incremental steps that are preferred by strategic family therapists.

The systemic therapist introduces new information in an effort to bring about systemic change. When Bateson¹⁴ wrote that information is “news of a difference,” he meant that we only register information that comes from making comparisons. He and other systemic therapists use circular questions, which are aimed at surfacing differences around time, perception, ranking on a characteristic, and alliances within a family. Linear questions (e.g., “What made you depressed?”) ask family members about cause and effect. Circular questions (e.g., “Who is most concerned about mother’s depression? Then who? Then who?”), by contrast, take a problem and place it within the web of family relationships. Other circular questions (e.g., “Who in the family is the most concerned about Pam?” “When were things different in the family, when you weren’t worried about Pam?”) attempt to elicit hidden comparisons and useable information.

In addition, systemic therapists employ two additional kinds of interventions, the reframe and the ritual. Reframing offers interpretations of problematic behaviors that are neutral or positive and that connect everyone in the family. The therapist uses positive connotation in redefining a problem to encourage cooperation, to introduce the idea of volition when behaviors have been regarded as outside of anyone’s control, and to introduce confusion as a means to stimulate new thinking around tightly held beliefs.

A ritual is introduced, not as a behavioral directive, but as an experiment.¹⁵ This therapist does not care if the ritual is carried out exactly as prescribed, since it is the ideas contained in the ritual that contain the power to change. When families enact two inconsistent behaviors simultaneously, a ritual can introduce time into this paradoxical system. With the Beans, the therapist might be struck by the ways that Mr. and Mrs. Bean treat Pam simultaneously as both a young girl and a young woman, undermining each other’s position so that the parents are never on the same page at the same time. This therapist might suggest the following “odd-even day” ritual: “On Monday, Wednesday, and Friday, we would like you to regard Pam as a little girl who can’t manage basic functions (such as eating). On Tuesday, Thursday, and Saturday, we’d like you to think about Pam as a young woman who is getting ready to leave home.” The parents are given the opportunity to collaborate on a shared view of their daughter at the same time, first as a girl, then as a young woman.

Rituals and reframes were usually introduced at the conclusion of a five-part meeting with a team of therapists and a family.¹⁶

The Practice

At the outset, this therapist, working either with or without a team, generates a few hypotheses to be confirmed or discounted using circular questions.¹⁷ One hypothesis is that Pam’s anorexia serves to keep her parents distracted from their own marital conflicts, which might escalate if they didn’t have Pam to worry about. For example, the following circular questions could be asked: “If in five years Pam has graduated from college and is of normal weight, what would your relationship as parents be like?” “Who is most worried about Pam?” “If you weren’t worried about Pam, where would that energy go?”

In trying to assess the validity of this hypothesis, the therapist pays attention to both the verbal responses of each family member and the nonverbal signs of interest in the questions. If family members seem interested in each other’s responses, and if their answers are thoughtful rather than automatic, the therapist would likely craft an end-of-session intervention based on that hypothesis. The therapist might say to the Bean family, “I’m sorry that Pam feels that she has to sacrifice her well-being, health, and future to distract her parents from fighting or from being unhappy with one another. Mr. and Mrs. Bean, I think you should go out alone without informing Pam where you are going, nor when you are returning. Later, please record in a diary how she responds to this ritual.” This message positively connotes Pam’s anorexia and connects everyone in the family. Moreover, this is a ritual prescribed at the end that is an attempt to clarify generational boundaries.

The Proponents

Systemic family therapy was forged by a quartet of psychoanalysts (Drs. Mara Selvini Palazolli, Luigi Boscolo, Gianfranco Cecchin, and Giulana Prata) who collaborated from 1971 to 1980 in Milan, Italy; they developed a multipart team approach and used a one-way mirror to observe interactions. In the first part, or “presession,” the team generates initial hypotheses that are based on referral information, such as “Who made the initial call?” and “What was the emotional tone on the phone?” as well as on clinical experiences of team members. In the second part of the team approach, one clinician interviews the family while the remainder of the team watches from behind a one-way mirror. The interviewing therapist seeks to confirm or refute the team’s hypotheses by use of circular questions. During the third part, or “intersession,” the team members create an intervention, which connects everyone in the family and offers a reframe or ritual. Often these messages are succinct, enigmatic, hypnotic, and intended to introduce enough new information to produce change in the system.

The Milan school was also responsible for the introduction of the notions of circularity and neutrality. Circularity refers to thinking that emphasizes patterns, recursiveness, and context. Circular questions allow the therapist to be curious about the patterns of interaction in a family that are destructive to everyone, without blaming any one individual. The therapist’s nonevaluative stance conveys respect and acceptance of the system, and it is synonymous with neutrality.

The Metaphor

This therapist is like the detective in a British mystery who interviews all of the suspects about a crime and then gathers them all in the parlor to tell them how the crime took place. The story he or she tells connects everyone’s point of view, but is generally different from any one person’s account. The experience of the reader of the story is to feel both confused and that the story makes perfect sense, even though it means reevaluating each person’s point of view. This mixture of confusion and resonance is what the systemic therapist aims for when he or she introduces a systemic opinion that alters meanings.

The Theory

Narrative family therapists rely on the transformative power of new language to create change. They posit that families get stuck because they have become constrained by a problem-saturated story and by constricted ways of talking among themselves about their difficulties. This therapist tries to identify the dominant stories that limit the family’s possibilities, and then to amplify minor or undiscovered narratives that contain more hope for change. Dominant stories include beliefs that the family holds about itself, as well as any cultural stories (e.g., the idea that adolescents can only become adults through rebellion and rejection of their parents) that may influence the family.

These therapists use story in two significant ways: first, to deconstruct, or to separate, problems from the people who experience them; and then to reconstruct, or to help families rewrite, the stories that they tell about their lives. These complementary processes of deconstruction and reconstruction are exemplified in the technique of externalizing the problem.¹⁸ With this technique, the therapist and the family create a name for the problem and attribute negative intentions to it so that the family can band together against the problem, rather than attack the individual who has the problem. The therapist subsequently asks about “unique outcomes,” or times when the patient was free of the problem. The family is asked to wonder what made it possible at those times to find the strength to resist the pull of the problem. In time, these unusual moments of resistance are amplified and added to by more stories that feature the patient as competent and problem free.

Narrative therapists have also developed the concept known as the reflecting team, to aid in the treatment of families and the training of therapists.^19,20 With this approach a group of clinicians observe an interview through a one-way mirror, and then speak directly to the family, offering ideas, observations, questions, and suggestions.²¹ These comments are offered tentatively and spontaneously so that the family can choose what is useful from among the team’s offerings and reject the rest. Several narrative assumptions form the underpinning of the reflecting team²²: the abundance of ideas generated by the team will help loosen a constricted story held by the family; the relationship between the therapist and the patient should be nonhierarchical (with an emphasis placed on sharing rather than on giving information); people change under a positive connotation; and there are no right or wrong ideas, just ones that are more or less helpful to a family.

The Practice

This therapist might begin by asking the Beans how they would know when the therapy was over. More specifically, he or she might ask the De Shazer miracle questions,²³ “If there were a miracle that took place overnight and Pam were no longer anorectic, what else would be different? How would the family be different? How would each of you be interacting with her?”

The therapist would also ask questions to deconstruct the present problem by externalizing it. For example, he or she might say to Pam, “This culture helps anorexia trick young women into thinking that they will be more loveable and successful if they lose weight. What tricks has anorexia used on you?” And in an effort to construct a new story, the therapist might inquire of each of family member, “Who would be most surprised to learn that Pam has turned her back on anorexia and is taking charge of her future? When do you observe Pam saying ‘no’ to the tricks of anorexia and investing instead in a realistic view of herself, based on her gifts and talents?” With these questions, the narrative therapist is looking to expand and to elaborate on alternative versions of Pam that do not include her identification with an eating disorder.

Another narrative tact is to ask the Beans about the influence of culture on the problem. For example, “Do the Beans endorse the culture-based story that girls need to reject their mothers in order to grow into women?” The therapist is trying to uncover the stories that give meaning to the Beans’ view of Pam’s upbringing, stories that may constrain, rather than expand, possibility.

The Proponents

Michael White, in Australia, and David Epston, in New Zealand, are the best-known thinkers and writers of the narrative approach.²⁴ In addition to their ideas of deconstructing the problem through externalizing and reauthoring, they have emphasized the political and social context in which all clinical work occurs. Relying on the work of Foucault, they critique the professional’s linkage of power and knowledge. For example, they do not make diagnoses or rely on medical records kept private from their patients. Instead, they may write a letter to a patient at the end of the session and use the same letter as the clinical note for the medical record. At the close of therapy, the record may be given to the patient or, with permission, shared with other patients who are struggling with similar difficulties.

The invention of the reflecting team is credited to Tom Andersen and his colleagues at the Tromso University in Norway in 1985. Observing the interview from behind the mirror, Andersen found that the therapist continued to follow a pessimistic view of the family, regardless of the reframing questions that were phoned in by the team. Finally, after several attempts to redirect the interview were thwarted, he “launched the idea to the family and the therapist that we might talk while they listened to us.”²⁵ With the team speaking directly to the family, presenting multiple ideas in an unrehearsed way, the concept of the reflecting team took root.

The Metaphor

The narrative family therapist is like a biographer who takes the family’s basic stories and transforms them with a different organization, a richer grasp of language and tone, and the addition of previously overlooked tales. The resulting story is a collaboration between therapist and family and contains story lines that hold more possibility than did the original story.

The Theory

Behavioral family therapy^26–28 derives from social learning theory, with particular attention paid to demonstrating empirical evidence for interventions. In this model, family systems represent members’ best attempts to achieve personal and mutual rewards while avoiding negative consequences. In order for maladaptive behaviors to endure, they must be modeled or reinforced somewhere within the system. The therapist and the family will collaborate in an effort to identify behavioral patterns and sequences that are problematic. The therapist then employs varied, empirically supported behavioral techniques to promote the learning of new adaptive behaviors while extinguishing their problematic predecessors.

The Practice

Behavioral family therapy relies on the ability to perform a detailed, functional behavioral analysis. The therapist begins with an assessment of the thoughts, feelings, and behaviors of each individual family member as they relate to the problem. Next, the therapist works with the family to detail representative sequences of behaviors that mark their current distress. For example, the therapist might ask the Bean family to recount with as much accuracy as possible a recent evening that culminated in an argument between Mrs. Bean and Pam over Pam’s refusal to eat dinner. If dinnertime proves a particularly reliable time for conflict, the therapist might ask the family to tape record the evening events for a week (or at least make notes in a journal) to allow for more accurate observation.

The behavioral therapist will try to identify factors that both precipitate and relieve the problem. (Does Pam’s refusal to eat correlate in any way with Mr. Bean’s business trips? Have there been periods where the issue of Pam’s eating seemed to be less of a struggle?) The consequences of the behavioral sequence are also of importance. (Do arguments between Mrs. Bean and Pam ultimately transform into arguments between Mr. and Mrs. Bean? Will Ellen typically come home from school on the weekend if she has learned of Pam having a difficult week?)

Ultimately, a hypothesis is generated as to the way each problematic behavior might be reinforced and what interventions might result in its extinction. The Bean family would be encouraged to choose specific goals. The therapist then acts as a collaborator and teacher, designing experiments that will test for behavioral changes. These will often be in the form of homework, but can also be conducted within the session. The results of these experiments will be analyzed with the same rigor of the initial assessment in order to assure all that they are proving objectively beneficial. Techniques include contingency contracting (Mr. and Mrs. Bean make reciprocal commitments to exchange positive regard for each other daily) and other operant reinforcement strategies (Mrs. Bean praises Pam’s partial completion of meals, and does not comment on what is left over). Behavioral family therapy techniques have established empirical support across a broad range of conditions,^29–37 both as individual interventions and as adjuncts to other treatment modalities.

As the family collaborates experimentally with the therapist, there may be times when the stress of a crisis exceeds the family’s current ability to effectively problem-solve. (Pam’s medical condition declines, and Mr. and Mrs. Bean are unsuccessful in persuading Pam to consider hospitalization.) At these times, the behavioral therapist may take on a more directive role to assist in crisis management.

The Proponents

Robert Liberman³⁸ and Lawrence Weathers³⁹ have made major contributions to the field of behavioral family therapy, including their application of contingency contracting. This form of operant conditioning recognizes that families in distress tend to have an increase in aversive exchanges marked by negative affect. In the contingency contract, family members agree to undertake structured interactions designed at improving positive exchanges. Gerald Patterson,⁴⁰ along with Marion Forgatch,⁴¹ has explored the way family systems reinforce aggressive behavior in adolescents. The reinforcement is characterized by intermittent punishment, empty threats, and parental irritability. Falloon and Liberman’s⁴² attention to levels of expressed emotion within families has informed both the behavioral and psychoeducational schools of family therapy.

The Metaphor

This therapist is like the civil engineer called on to reconfigure well-established traffic patterns in a busy city. Congested areas must first be analyzed with respect to why drivers consistently choose these routes despite the availability of alternatives. Next, attention should be paid to how various interests (individual, government, business) might be affected by potential changes. Concerned parties would be solicited to express their concerns. Subsequently, a reorganization can be introduced in a stepwise fashion, interrupting prior patterns in an attempt to foster new ones. With each incremental change, traffic flow is measured and adjustments are made accordingly. Ultimately, the solution seeks to serve efficiency while maximizing the satisfaction of the individual, government, and business sectors.

The Theory

Psychoeducational family therapy^26–28 originated to assist families caring for a member with severe mental illness and functional impairment. The therapist understands family dysfunction as deficits in acquirable skills and knowledge. Through education and focused skills training, families and patients are empowered to effect their own change. The therapist anticipates deficiencies in several key domains. These include communication, problem solving, coping, and knowledge of the illness. The therapist is also vigilant in identifying relationships that appear overinvolved or hypercritical, because these are associated with an increased likelihood of relapse and exacerbations of the affected member’s illness. The goal of therapy is to create an environment that is more deliberate in its fostering of mastery and recovery.

The Practice

Psychoeducational family therapy is conducted with individual families and with family groups. The treatment typically takes place in discreet phases that can be manualized for various disorders and contexts. Introduced at a time of crisis, the psychoeducational family therapist would begin with the Bean family during an inpatient hospitalization for Pam. Mrs. Bean could be allowed to mourn the loss of her healthy daughter. Ellen would be encouraged to offer happy memories of Pam before the onset of illness, illustrating family strengths in the process. During this first phase, referred to as engagement, the therapist seeks to establish an alliance with the family while evaluating their approach to crisis management. The therapist would seek detailed information regarding family communication styles and coping strategies while monitoring alliances and divisions. The therapist would hope to reassure the family about Pam’s condition and set the stage for their participation in her treatment as effective agents of change.

Following engagement, the Bean family would be invited to an educational workshop along with a group of other families in a similar situation. Families would be provided with essential information to inform their understanding of the diagnosis, treatment, and prognosis of anorexia nervosa. Mr. and Mrs. Bean’s expectation of Pam’s rapid recovery following hospitalization would be challenged, along with reassurance that the expectable prolonged course does not preclude eventual recovery. Ellen’s fear that Pam’s amenorrhea would prevent future fertility would be dispelled. To the extent possible, the family would be encouraged to maintain regular schedules and activities. Warning signs of future relapses would be highlighted.

The next phase is marked by the process of Pam’s reentry into the community. The Bean family might meet twice weekly over the first few weeks following discharge. The therapist would offer methods designed to achieve goals important to this period. These include the maintenance of good interpersonal boundaries despite heightened anxiety and protectiveness, medication and appointment compliance, and surveillance for warning signs of impending relapse. Mr. and Mrs. Bean would receive guidance on how to effectively communicate with each other, Pam, and people outside the family as Pam begins to socialize with peers following her hospitalization.

The last phase, rehabilitation, focuses on the family’s task of encouraging the slow, progressive increase of Pam’s independence and responsibility for her condition. The therapist could advise the Bean family to speak with other families who have been successful in maintaining recovery from anorexia. Following months to years of cautious, gradual efforts, the Bean family would begin to anticipate the process of Pam going away to college.

The Proponents

Psychoeducational family therapy finds its origins in the treatment of schizophrenia. Carol Anderson⁴³ developed a psychoeducational model for schizophrenia, which she later adapted to affective disorders. William McFarlane⁴⁴ is responsible for the psychoeducational model illustrated in the previous example, which also was designed for families coping with schizophrenia. In his model, several families with schizophrenic members meet together for psychoeducation. Psychoeducational methods are finding continued empirically supported applications for schizophrenia,⁴⁵ as well as conditions outside of the formal thought disorders,⁴⁶ and will likely continue to expand to additional diagnoses and contexts.

The Metaphor

This therapist is like a wilderness guide leading amateur enthusiasts into a state park. Before setting foot on the trails, basic myths of the forest are dispelled through basic classroom instruction. Prospective campers might learn that no snakes indigenous to the area are poisonous, while being cautioned that some innocent-looking mushrooms are. The guide then begins to lead expeditions of increasing difficulty, pointing out examples from the classroom while gradually assigning more responsibility to the campers. Finally, before letting the group explore on their own, the guide distributes flares and radios, so that help can easily be accessed should the need arise.