Overview of the family

Families are defined by reciprocal relationships in which persons are committed to one another. Duvall (1957) was among early writers to describe the level of maturity of families as units. She addressed the quality of family functioning, noting that at one extreme some families function in immature or infantile ways, while at the other extreme, families may function in particularly healthy or adult-like ways.

The notion of family function refers to a range of characteristics. They include the family’s:

When Duvall described family functioning, she was referring to the “nuclear family”—mother, father, and children—that was prevalent in the 1950s. Today, family constellations are more complex. The National Health Interview Survey (Blackwell, 2010) identified the following types of families with children that exist in the United States:

Still, Duvall’s descriptions of family dynamics that describe family functioning on a maturity continuum remain useful in describing family dynamics, despite the increasing complexity of family makeup. The level of functioning of the family unit, regardless of its constellation, will influence the family’s individual and collective abilities to deal with life events (Young, 2010).

The family is the primary system to which a person belongs, and in most cases, it is the most powerful system of which a person will ever be a member. The dynamics of the family subtly and significantly influence the beliefs and actions of individual members across the lifespan. Healthy families—those whose members communicate well, maintain fairly consistent expectations and roles, can support and nurture each other, and are adaptable in the face of change and stress—tend to deal better with developmental changes than do less healthy families. But the process of adaptation, even to “normal” changes such as the birth of a child, can test the strength of relationships even in the most resilient family. In those situations, family therapy can be beneficial to the overall functioning of the family and to the individual members as well. Family therapy provides an opportunity for emotional and social growth. In family therapy, a focus on family functions is aimed toward strengthening family interactions to foster family maturity.

As the notion of family has broadened to incorporate nontraditional family structures (Figure 34-1), family therapists and counselors have been challenged to recognize and incorporate similarly broad definitions of family in their work. Despite the increasing complexity of family definitions, family health still can be measured in terms of quality of communication, consistency of familial expectations and roles, support and nurturance of one another, and adaptability in the face of change and stress (Coulter & Mullin, 2012). The family provides an essential training ground for developing individuals’ future skills for interacting in the greater community, and it is within the family that each of us initially learns sets of long-standing and fairly permanent social and emotional responses. Because family functioning represents behaviors that involve dynamics that extend beyond individuals to individuals-in-interaction, fully understanding the forces that influence family functioning is challenging. That is the challenge accepted by family therapists as they address family functioning.

Family functions

A healthy family provides its members with tools to guide effective functioning within the family and extends to functioning in other intimate relationships, the workplace, culture, and society in general. These tools are acquired through the activities associated with family life and include management activities, boundary delineation, communication patterns, emotional support, and socialization (Nichols, 2009). Although family therapists may use various assessment strategies, these five areas are always included. Figure 34-2 presents an assessment overview developed by Roberts (1983) that can be used to examine and measure the effectiveness of family skills in these five areas.

Management

Every day in every family, decisions are made regarding issues of power, resource allocation (i.e. who gets what), rule making, and the provision of financial support. These decisions contribute to adaptive family functioning. In healthy families, it is usually the adults who mutually agree about how these management functions are to be performed. In families with a single parent, these management functions may sometimes become overwhelming, as the parent has no partner with whom to discuss management functions.

In more chaotic families, an inappropriate member, such as a teenager, may be the one who makes management decisions. Although children learn decision-making skills as they mature and increasingly make decisions and choices about their own lives, they should not be expected or forced to take on this responsibility for the family. A 12-year-old child, for example, should not be the one to decide whether to pay the gas bill or buy groceries.

Strong management supports the quality of day-to-day family operations. Assessing management functions contributes to a broad conceptualization of the quality of family functioning.

Boundaries

Boundaries serve to maintain distinctions between and among individuals in the family and between the family and individuals external to it. Establishment and maintenance of flexible and appropriate boundaries is essential to healthy family functioning. Boundary management is an important skill for families and often is a primary focus of family therapists. Minuchin (1974) identified three predominant types of boundaries within families: clear, diffuse, and rigid. Clear boundaries are adaptive and healthy. They are well understood by all members of the family and give family members a sense of “I-ness” and also “we-ness.” They are firm, yet appropriately flexible, and provide a structure that responds and adapts to change. Clear boundaries allow family members to enact roles appropriately and to function without unnecessary or inappropriate interference from other members. They reflect structure and flexibility; at the same time, they support healthy family functioning and encourage growth in family members, often referred to as “differentiation” (Schnarch & Regas, 2011).

For example, a mother maintains her role as the parent by telling her 14-year-old son, “You don’t need to worry whether your little brother eats his breakfast. Your father and I will handle that.” This boundary, however, is not rigid and may be redefined from time to time, as in, “I want you to make sure that your little brother gets his homework done while your father and I are at the movies.”

Diffuse or enmeshed boundaries are less supportive of family health and often are enacted in families in which members are overinvolved with one another. When boundaries are diffuse, individuals tend to become “enmeshed.” As a consequence, it is not clear who is in charge, who is responsible for decisions, and who has permission to act or take charge. Diffuse boundaries are particularly problematic when parent/child role enactment becomes blurry. For example, when a parent is unemployed and one of the children takes responsibility for earning money to meet the family’s basic needs, boundaries can be said to be diffuse.

In families with diffuse boundaries, individual family members are discouraged from expressing their own views or to differentiate. Thus, to an outsider, it may appear that family members are extremely close, and family members may believe that they are of one mind. That sense is typically false though, and deeper analysis often results in the discovery of suppressed frustrations, anger, and behaviors.

Because in enmeshed families any expression of separateness or independence is viewed as disloyalty to the family, members are prone to psychological or psychosomatic symptoms, probably as a function of the individuals’ inability to actually say or even to recognize how they feel. During times of change or crisis, whether the crisis is one of normal development (such as when a new baby is born or an elderly grandparent dies) or is one that is unanticipated (such as the loss of a pregnancy, or serious, debilitating injury to a family member), adaptation of both individuals and of the family as a whole is extremely difficult.

When boundaries are diffuse, everyone, and thus no one, is in charge. Individuals expect other members of the family to know what they are thinking (“Why did you take that? You know I wanted it!”), believe they know what other family members are thinking (“I know exactly why you did that!”), and take comfort that everyone thinks the same way (“No one in our family likes seafood.”). Assumptions at this basic level challenge the growth and maturation of the family over time, often serving to urge the family into family therapy.

Rigid or disengaged boundaries are characterized by the consistent adherence to rules and roles—some apparent and some less so—no matter what. Boundaries can be so closed that family members avoid each other, facilitating little sense of family loyalty. In that case, families are considered to be disengaged. In families in which rigid boundaries predominate, communication is minimal, and thoughts and feelings rarely are shared. Isolation may be marked.

Disengaged family members lead highly separate and distinct lives, and no one is really involved with anyone else. Since intimacy is not learned in the family setting, individuals from disengaged families do not tend to develop insights into their own feelings and emotions. As a result, they may have a hard time bonding with others and participating in new family structures when they leave their families of origin and begin their lives as adults.

VIGNETTE

Lauren is a single, teenage mother living on public assistance; she has two preschool-aged children. Lauren is studying for a general equivalency degree and working part time as a seamstress. Her mother, Sandra, helps to watch the children, and the discipline of the children is an issue of contention between Lauren and Sandra. Sandra thinks that the children are allowed to run wild under Lauren’s care. The lines of authority between Sandra as mother, Lauren as daughter, and Sandra as caregiver are blurred.

Sandra does not speak to Lauren about her concerns, but her nonverbal communications clearly express her feelings. Likewise, Lauren does not address her mother’s attitude toward her parenting style. Instead, she complains about her mother’s child-care skills to her friends and to her siblings. Neither Lauren nor Sandra is experiencing growth from this rigid set of expectations. Meanwhile, the children are learning poor communication skills.

When boundaries are functioning properly, family members work out arrangements in compromise based on understanding of appropriate roles and on open communication. Each generation within the family is made tacitly and explicitly aware of how decisions will be made. Individuals are clearly and appropriately involved in discussion so that they understand who is in charge and know when they are in charge. There is flexibility and room for discussion as family members work out difficult situations.

Alternatively, blurred boundaries, whether they are diffuse or rigid, result in family members interfering with each other’s goals, in tension and anxiety between family members, and in intrapersonal anxiety. Children living within families with blurred boundaries become confused, tending to engage in manipulative and perhaps age-inappropriate behavior, and feel insecure and helpless as they mature.

Communication

Communication patterns are extremely important in family life. Healthy communication patterns are characterized by clear and comprehensible messages (e.g., “I would like to go now” or “I don’t like it when you interrupt what I’m saying”). Healthy communication within the family encourages members to ask for what they want and need and to express their feelings appropriately. Thoughts and feelings can be openly, honestly, and assertively expressed in families where communication is healthy. Family members are able to ask for what they want and get the attention they need without resorting to manipulation. Alternatively, those in legitimate positions of power within the family, typically the parents, are able to make determinations about the appropriateness of requests.

In healthy families, there is a necessary and natural hierarchy, or power difference, for the protection and socialization of younger family members. Parents are the leaders in the family and children are the followers. Despite this arrangement, children can voice their opinions and have influence on family decisions. In dysfunctional families this seemingly simple equation goes off track. If the communication roles match speakers’ functional roles—when, for example, parents communicate like parents—the communication remains clear; however, if a parent communicates like a child, refusing to enact communication expected of a parent, the child may need to take on a reciprocal parental communication role, significantly confusing both communication and boundary functions (Harris, 1967; Nichols, 2009).

When communication among family members is unclear, and when roles and the natural hierarchy become confused, communication cannot be used as a means to solve problems or to resolve conflict. The cardinal rule for effective and functional communication in families is “Be clear and direct in saying what you want and need,” whether you are in a powerful or a subordinate position. As simple as this may seem, communication is one of the hardest skills to activate in a family system. To be direct, individuals must first have a sense that they are respected and loved and that it is safe to express personal thoughts and feelings. The consequences of being clear and direct may be unpleasant in a family system that will not tolerate openness.

The following vignette describes a spousal situation that shows how easily communication can be misunderstood when clear and direct messages are not sent, and Box 34-1 identifies some unhealthy communication patterns.

BOX 34-1      EXAMPLES OF DYSFUNCTIONAL COMMUNICATION

Manipulating

Instead of asking directly for what is wanted, family members manipulate others to get what they want. For example, a child starts a fight with a sibling to get attention. Another example is a family member’s making requests with strings attached so that the other person has a difficult time refusing the request: “If you do this for me, I won’t tell Daddy you are getting poor grades in school.”

Distracting

To avoid functional problem solving and resolving conflicts within the family, family members introduce irrelevant details into problematic issues.

Generalizing

When dealing with problematic family issues, members use global statements such as “always” and “never” instead of dealing with specific problems and areas of conflict. Family members may say “Harry is always angry” instead of “Harry, what is upsetting you?”

Blaming

Family members blame others for failures, errors, or negative consequences of an action to keep the focus away from themselves. This is a response to fear of being blamed by others.

Placating

Family members pretend to be inadequate but well meaning to keep peace in the family at any price: “Don’t yell at the children, dear. I put the shoes on the stairs.”

VIGNETTE

Liz would like to spend more time with her husband, Michael, on the weekends; however, Michael always seems to be busy doing projects around the house or talking with friends on the telephone. Liz believes that Michael does not notice her or maybe is not interested in her, so she spends a lot of time working out or playing tennis. Michael figures that Liz is doing what she wants to do and that it makes her happy, so he contents himself with finding things to do alone. The result is that Liz and Michael spend little time together.

Liz finally confronts Michael clearly, directly, and assertively, rather than angrily or aggressively, about her belief that he is “disinterested” in her and tells him what she wants and needs—to spend more time together on the weekends. Michael replies that he had no idea she felt that way. He had thought she enjoyed the way things were, and he would like to have more time together too.

Emotional support

All families, regardless of how healthy they are, encounter conflicts. In the most functionally healthy families, feelings of affection generally are uppermost, and family members realize that bursts of anger and conflict reflect a short-term response. Anger and conflict do not dominate the family’s pattern of interaction.

Healthy families are concerned with one another’s needs, and most of the family members’ emotional and physical needs are met most of the time. When members’ emotional needs are met, they feel support from those around them and are free to grow and explore new roles and facets of their personalities. A family that is dominated by conflict and anger alienates its members, leaving them isolated, fearful, and impaired emotionally.

Socialization

It is within families that individuals first learn social skills, such as how to interact in nonfamily venues, how to negotiate for personal needs, and how to plan. Children learn through role modeling and through behavioral reinforcement how to function effectively within the family and, when the system is successful, how to better develop an ability to apply those skills in society as adults. Parents are socialized into family roles as adult members as they address the growth and development and specific needs of each child throughout their developmental stages. Parents’ roles change when the children mature and leave home; this may necessitate partners’ renegotiation of the patterning of their lives together. As time goes on, the parents may need their adult children’s help if they become less able to care for their own needs.

Each developmental phase for family members and for the family as a whole brings to bear new demands and requires new approaches to deal with changes. It is not surprising that families typically have difficulty negotiating role change. Change increases stress within families, sometimes for short periods if the family has in fact incorporated functioning that works well for them and their members, and sometimes for longer periods if the family functioning is not working well for all.

In response to the demands of change, healthy families demonstrate flexibility in adapting to new roles. Through well-organized management activities, firm but flexible boundary delineation, strong and appropriate communication patterns, ongoing provision of emotional support, and adept socialization, healthy families provide tools to their members to facilitate functioning for the present and into the future.

Overview of family therapy

Family systems theory posits that interventions aimed especially toward addressing family dynamics will decrease emotional reactivity, encourage differentiation among individual family members (i.e., increase each member’s sense of self), and/or improve patterns of family interaction. Interventions include encouraging family members to consider emotional patterns learned in their families of origin and to make use of family resources to engage in patterns of interaction that take them beyond the emotional responses of their pasts. Family members whose actions, perceptions, or beliefs are identified as problematic receive counseling and behavioral therapy encompassed in family work. The focus of family therapy is not on the problematic individual, however. Instead, it is on the ways the dynamics of the family system may contribute to the problems of individual family members.

By the 1960s and 1970s, therapists in clinical settings were beginning to notice the effects of the social milieu on their patients. At that point, the therapeutic community became established as a treatment modality, and group therapy and psychodrama were developed. All these changes were based on observations of patients and on an expanding belief that social systems played an integral role in psychological functioning and treatment. An interactive (interpersonal) rather than indwelling (intrapsychic Freudian) model of mental illness was becoming more widely accepted as family therapy took root in psychiatric care, paving the way for an interest in the family system as it related to psychiatric disorders.

Changing dynamics in families are difficult to recognize when they occur slowly over time. Thus, it is possible for the identified patient in a family to enact behaviors that get just a little bit worse every day or every week, sometimes for years before they become problematic. At the same time, before they are aware of the growing complexity of their dynamics and of changes in their patterns of interacting, family members can find themselves embroiled in situations they find intolerable. They may not recognize that their patterns of interrelationship have changed, finding only that the family no longer offers a sense of love, safety, value, and security. Thus, family members do not always welcome family therapy, as families adjust slowly to their new, if ultimately uncomfortable, ways of being together over time. Often the early sessions in family therapy are inadvertently threatening to family members because change is always difficult. The effective family therapist will demonstrate facility in recognizing and responding to family members’ anxieties and concerns and will work to modify approaches accordingly to encourage the family to remain engaged.

Although there are a number of approaches useful in conducting family therapy, generally speaking, those approaches fall into one of two broad classifications or paradigms. One paradigm—Insight-Oriented Family Therapy—focuses on developing increased self-awareness, other-awareness, and family awareness among family members. The other paradigm—behavioral family therapy—focuses on changing behaviors of family members to influence overall patterns of family interactions. Table 34-1 lists specific therapies that can be classified within each paradigm, highlighting major concepts related to each individual therapy, and identifies some of the therapists who contributed to their development and use.

TABLE 34-1   

INSIGHT-ORIENTED AND BEHAVIORAL THERAPY

TYPE OF THERAPY	CONCEPTS	MAJOR THEORISTS
Insight-Oriented Family Therapy
Psychodynamic therapy	Problems arise from developmental arrest,current interactions, projections, and current stresses Goal is to gain insight into problematic relationships originating in the past	Nathan Ackerman James Framo Ivan Boszormenyi-Nagy
Family-of-origin therapy	Emphasis is on the family of origin Family viewed as an emotional relationship system Triangulation Goal is to foster differentiation and decrease emotional reactivity	Murray Bowen
Experimental-existential therapy	Symptoms express family pain Family is responsible for its own solutions Therapist uses nurturing and identifies dysfunctional communication patterns Goal is to encourage growth of the family	Carl Whitaker Virginia Satir Leslie Greenberg Susan Johnson
Behavioral Family Therapy
Structural therapy	Focus is on organizational patterns, boundaries, systems and subsystems, and use of scapegoating Enmeshment and disengagement Boundaries clarification Restructuring of dysfunctional triangles	Salvador Minuchin
Strategic therapy	Identifies inequality of power, life-cycle perspectives, and use of double-bind messages Paradox Prescribes rituals Goal is to change repetitive and maladaptive interaction patterns	Jay Haley Chloe Madanes Milan group (Mara Palazzoli, Gianfranco Cecchin, Giuliana Prata)
Cognitive-behavioral therapy	Based on learning theory Focus is on changing cognition and behavior Skills training is emphasized	Gerald Patterson Richard Stuart Robert Liberman

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