Psychosocial Approaches

Family Therapy Approaches

Observer to situation describes family problems More than one member involved in presenting problem Several presenting problems affecting different family members Previous attempts to help have failed Different therapeutic, legal or statutory agencies involved

Key ideas Historical Context

Communication theory (Bateson 1972) different levels of meaning - verbal and non-verbal Context - provided meaning to behaviour

1960s - Laing - examined relation between schizophrenic patients and their mothers

Punctuation - circular process between cause and effect describe form and pattern of organisation of behaviour Mapping differences in relationships between family members - by team work

Structural Family Therapy (Minuchin 1974)

1970s later emphasized evolving nature of problems and observer = part of the system - systemic therapists Social constructivism (Hoffman 1988) reality = socially constructed. Number of versions reality = number of observers Emphasises language - stories about reality and therefore problems = created in language Therapy = attempt to create different stories for people who present with problems.

Concerned with family structure

Healthy family clear organisation hierarchy well defined permeable boundaries

Boundaries ensure privacy autonomy individuality Family life cycle - development occurs through a series of normative transitions which characterise each life stage Problems arise at points of transition. If family has difficulty adjusting to a new structure, interventions unblock obstacles in normal development process.

Genogram

Genogram
. Essential tool in therapy.
Look for patterns between and within generation Highlight patterns Determine extent to which presenting family adheres to normative structure Note alliances and coalitions Challenging family structure through enactment and sculpting Offer alternative ways of oeprating Most researched methods Particularly effective with psychosomatic problems in children (Minuchin, Rosman and Barker 1978)

Brief Therapy Model

Focus on solutions rather than problems - if something works do more of it, if not do something different. Focused and goal directed. Problems develop and are maintained in context of human interaction. Need to understand constraints of complaint situation. Aim = help individual do something different by changing the way which interact with each other. Assumes clients know what to do to solve problems but do not know they know.

Therapist role = use knowledge which have Approach

Narrow Focused Goal directed

Systemic Approach - Milan approach

Palazolli, Prata, Boscolo and Cecchin 1978 Developed with families containing anorexic or schizophrenic member - but now applied more widely. Systems reach a stable organisation round a double bind or paradoxical injunction. Aim therapy = change rules which organises system to eliminate the symptom.

Palazolli et al 1980
5 stage session guided by 3 principles Hypothesizing - in pre session discussion - therapist and team put together information. Genogram constructed. Alternative hypothesis created to connect as many family members as possible. Circular questioning - makes connections between people, events and ideas. Gossiping in the presence of. Circular questions used to test teams hypotheses. Neutrality - all family members should feed equally engaged with the therapist. Neutrality to ideas - no one piece of information is any more important than any other piece of information.

Evaluation
Intervention - message to family - often paradoxical e.g. prescribing the symptom. Odd days, evens days rituals. Post session discussion - hypothesize about effects of intervention on family. Any action informs future intervention. Post Milan developments more dynamic view of systems therapists take a more active role in therapy
Gurman and Kniskein 1979 surveyed 200 studies 61% individual cases 73% family cases improved using a systemic family therapy approach. Family therapy no more effective than individual therapy. De Shazer et al 1986. Brief therapy. 1,600 cases seen for average 6 sessions. 72% met goals for therapy or felt significant change had occurred. Tomm 1984 - Milan team find improvement in 68% families

Criticisms

Family Models in Schizophrenia

Bateson et al 1956 Double bind theory to explain schizophrenics key problem, severe difficulty in the pattern of communication. Few empirical investigations difficult to identify double-bind messages such messages are likely to occur in all families Laing 1965. Symptoms of schizophrenia developed as a way of coping with and communicating to others the impossibility of the family environment.

Power - supports the nuclear family as the right way to live and this subjugates women Family therapy upholds middle class, white, western values. Therapists seen as manipulative social engineers

Brown et al 1966 expressed emotion within family level of EE = determined by frequency of critical comments and positive remarks and ratings of hostility, emotional over involvement and warmth in relative. Strong relationship between relapse and living with high EE relative.

Led to development of family interventions. Family interventions have been shown to significantly reduce relapse rates as compared with control groups (Leff et al 1982, Falloon et al 1982, Hogarty et al 1986, Tarrier et al 1988). Patients living with HIGH EE relatives have higher relapse rates than those with LOW EE relatives. Highest risk - those with >35 hours/week face to face contact and failure to receive regular medication.

Family Intervention
Reduces EE (a) Leff et al (1982) Information programme & relatives group & family therapy (b) Falloon et al (1982) Information programme & family problem solving (c) Hogarty et al (1986) Information programme & behavioural family therapy & social skills training