Family Therapy: History and Current Frameworks

Family Therapy: History and Current Frameworks 

Family therapy has been a discipline of psychotherapy since the 1960’s and has grown in several directions. Presently, it appears to be forming a solitary front under one meta framework through its growth. The name of this branch of psychotherapy differs depending upon the individual program which a therapist subscribes and the focus of practice. In addition to being called family therapy, it is also referred to as marital family therapy, couple’s marital family therapy, couple’s family therapy, and whole family therapy.  However, just as the name varies, so has the practice though the years which is now seeming to narrow its focus from many different working models to an integration of many different frameworks. Yet in narrowing its focus seemingly to one metaframework, it is broadening the base from which to work in a pragmatic manner. This will be shown as the history of family therapy is explored and several different current concepts of treatment with some of their components are examined with a limited scope.

The History of Family Therapy

Family therapy began in earnest during the 1960s as the practice of psychoanalysis had been replaced by fresh theories and additional scientific thought began to be applied to psychotherapy (Ember-Black, 2014). Scientific methodology had yet to be applied to psychotherapy. In the 1950s the individual was beginning to be viewed with the family and the relationships within the family began to be integrated into therapy as systems theory began an early influence although it was not yet identified within psychotherapy (Flaskas, 2010). The family was a unit in which the unit was stronger than the individuals which comprised it; what affected one affected all (Flaskas, 2010). The United States was undergoing significant change in the 1960s and family therapy sprang up along both coasts but was not yet openly accepted (Ember-Black, 2014). The field was a multidisciplinary one with psychiatrists, social workers, psychologists, and nurses all working together in collaboration without a pecking order of disciplines (Ember-Black, 2014). Yet the originators were for the most part therapists who were white, European men, and most were psychiatrists (Bruenlin & Jacobsen, 2014). Added to this rather homogenous mix were the theorists of whom few ever practiced, yet all attended conferences together where the therapists and theorists interacted and discussed presentations freely without ever coming into a formal alliance (Bruenlin & Jacobsen, 2014). With the paradigm shift of focus onto the family instead of just the individual member, many different models for treatment were presented with each having its own modality, making universal application claims, and being based upon its own assumptions; similarities between models were ignored and only the differences were emphasized and “model wars” broke out (Ember-Black, 2014). Although these early family therapy pioneers never addressed problems of gender inequality or spousal abuse and violence, they did address the issues of race disparity and the plight of the poor in the United States with its major disparity (Flaskas, 2010). Even though behavior was a focus in the individual, it began to be understood differently with the formal introduction of systems theory towards the end of the 1960s and early 1970s (Flaskas, 2010).

In the 1970s, major models of structural family therapy and strategic family therapy emerged in the United States (Flaskas, 2010). Gregory Bateson insisted upon the influence of the ecological perspective and saw all things as interconnected by relationship (Bruenlin & Jacobsen, 2014). He contended that the symptomatic individual should be a part of the family and therapy should be with the family, thereby pressing the issue of interconnectiveness (Bruenlin & Jacobsen, 2014). As Bateson’s understanding of systems theory was brought into play, circular causality – in which multiple interactions cause a systemic effect – replaced linear dyadic causality theory (Flaskas, 2010).  Systemic therapy began to question the individualized practice in which the medically stylized template was the preeminent style of treatment (Flaskas, 2010). Following the disruption of society in the 1960s and 1970s, the turn of the decade swept in a period of turbulence in psychotherapy which saw a significant shakeup.

A convergence of several lines of thought came into theoretical consideration as those radical societal changes caught up with the world of psychotherapy; feminist philosophies and post-modernist theories began to take shape along with the ecosystemic influence (Flaskas, 2010). Cybernetics and epistemology had circulated through the models because of the ecosystems influence (Flaskas, 2010). Everything seen as modernism was questioned including the position of the therapist as director and the therapeutic process was reshaped to be more of a collaboration with the client which brought dialogue and its meaning – collaborative language systems – into primary consideration.

During the 1980’s, the Milan therapy model also made its appearance along with the reflecting team and brief therapy (Flaskas, 2011). The Milan framework has continued to evolve from its original concept which included working within the family with family games to one of a relationship in which the therapist is part of a system with the family (Flaskas, 2011). North America was strongly influenced by the Milan model in the later 1980s and this framework was in turn influenced by the feminist, ecosystems, and post-modernist thinking (Flaskas, 2011). By the time the following decade arrived, something quite different from the family therapy of the 1970s had come into being.

Social constructionist and narrative frameworks influenced the models of the 1990s and language itself became important (Flaskas, 2011) Context and relationship were still central to therapy, but the concept changed as the therapist no longer directed but facilitated (Flaskas, 2011). Research based practice was emphasized as the query shifted from one of the effectiveness of family therapy to one of finding what would improve that effectiveness. Theories began to come on the scene which were empirically supported as the scientific method came prevalent in full force (Bruenlin & Jacobsen, 2014). Current models in use gave way to further refinement as brief therapy grew to solution-focused brief therapy and the Milan framework continued to evolve while narrative therapy made a significant impact (Flaskas, 2011). While the 1960s & 70s saw emerging frameworks, and the 1980s witnessed a transformation, the 1990s saw frameworks further articulated (Flaskas, 2010).

Following that refinement, social constructionism wielded a stronger influence and narrative therapy, which was developed mainly in the Dulwich Center of Adelaide, Australia, by social workers Michael White and Cheryl White, became strongly influential especially in Australia (Flaskas, 2011). Narrative theory formed with a family therapy orientation inside of a safe zone where blame was absent while emphasizing the strengths framework; a strong feminist influence became intrinsic to its concepts through Cheryl White’s formative leadership (Flaskas, 2011). The turn of the century had ushered further refinement into family therapy. 

With the enhancements to family therapy, context and relationships continue their historical relationship as language and the expression of the client began to be considered even more directly (Flaskas, 2010). The term “model” came to lose some of its luster in describing therapy so that the terminology now reflects the use of multiple frameworks which emphasize the broadness and plurality of applicable theories (Flaskas, 2011). One theory is not seen as an answer to everything; instead, there is a repertoire of frameworks without the concern for uniqueness, but in the recognition that there are many generic and common factors available with an integration of concepts (Flaskas, 2010). Instead of using a single methodology, a broad approach with multiple modalities available is now requiring disciplined reasoning skills and an open mind to select and use what will work for the client in the situation presented (Ember-Black, 2014). Another integration into family therapy is the influence of neurobiology and a growing understanding of the brain and its functions (Flaskas, 2011). Even with its complexity and manifold changes, family therapy continues today as a united front with a spectrum of available and proven treatment modalities which can be applied as the situation calls for it. Family therapy began as a combination of systemic theory with the idea of treating families together and, although it has gone through many theories, it is moving back toward an approach of using strategy and concepts from across varied theories (Hardy, Brosi, & Gallus, 2019). Several reasons play into this such as identification of the profession, no effective single mode of treatment, and the findings from common factors research; yet the reason is as much pragmatic as it is anything else (Hardy et al., 2019). In discussion of several theories of psychotherapy used by family therapy, striking similarities emerge to show that family therapy has an overarching metaframework from which the flexibility and utility are plentiful.

Integrative Systemic Psychotherapy

Integrative systemic psychotherapy (ISP) gives organization and a breadth of knowledge for the therapist to use in addressing the increasingly diverse families and their specific needs (Hardy et al., 2019). Many options and frameworks are available for use in choosing the appropriate techniques and model of therapy applicable to the client and the client family (Hardy et al., 2019). The ability of ISP to reach across several models and theories prevents being isolated into one model that may not fit the situation (Lorås, 2018). Another witness to the strength of this theory is seen in gathering theorists, therapists, and trainers into a close cohesion to find what is common from the expanse of models and then defining a collective view that leads to a means of training for a research-informed, comprehensive, integrated, and systemic approach to practice (Hardy et al., 2019).

ISP is a pragmatic response to the many models available for use in the 1990s; it began as building a single metaframework from which to use what worked best from all the models available while using the approach of systemic psychotherapy by following an outline of hypothesizing, planning, conversing, and feedback (Hardy et al., 2019). Identifying strengths, solutions, relationships and positive resources are the focus rather than placing a label upon the client (Lorås, 2018). The relational construct as well as the social construct are sought to be understood when considering the problems addressed within the context of the family (Lorås, 2018).

Solution Focused Brief Therapy

In solution focused therapy, the focus is upon the client family’s current successes and a successful solution from intake onward as a projected image of what is needed is developed and then worked toward (Flaskas, 2011). It is influenced heavily by social constructionism and is pragmatic with a post-modern influence in the position the therapist assumes; the client’s terms are used as they develop the discipline to attain the solution developed (Flaskas, 2011). In advancing that train of thought to solution focused brief therapy (SFBT), the client and therapist both must come to a clear understanding of each other though the prescribed methodology of SFBT (Choi, 2019). The reason it is called “brief” is that the need for a projected period of therapy is not necessary.

SFBT originally was based upon constructionist views of communication as well as social interactional theories (Franklin, Zhang, Froerer, & Johnson, 2017). It matured to include social constructionism and post-structural views of language (Franklin et al., 2017). Specific prescribed questions are used to promote attitude changes and to illicit response of positive emotions which lead to positive outcomes (Franklin et al., 2017). SFBT and linguistic techniques such as it has a strength in that both have a scientific basis for use and in effectiveness for a positive outcome (Franklin et al., 2017). A major factor of this therapy is its use of the strength’s perspective with the next strongest finding is the use of linguistic techniques and collaborative language to effect positive change (Franklin et al., 2017). An important factor is that SFBT requires specific training for language skills to be properly used in psychotherapy (Franklin,  et al., 2017).

One of the drawbacks of SFBT is to ignore the problems and emotions of the client as well as the relationship with the client by the therapist (Choi, 2019). This could result in the loss of a place to empathize with the client and thereby effectively ignoring the problem and empathy; these are both an important part of SFBT even if the focus is not upon the problem, but rather in finding the solution (Choi, 2019). The solution is traditionally built through not only solution talk, but through “solution-focused” problem talk (Choi, 2019). Thus, the solution is the focus, yet the problem is importantly acknowledged as the client’s strengths and own psychological resources are uncovered by the client and utilized for functional change and maintenance of that change (Choi, 2019). The nature and extent of the problem are uncovered with a genuine curiosity on the part of the therapist, allowing the client to verbalize, and listening with genuine interest (Choi, 2019).

Dialogical Theory

Dialogical theory is closely linked to the Milan-systemic framework in which the therapist listens from a non-expert point-of-view and the therapy becomes a linguistic event (Flaskas, 2011). It continued to evolve with the work and influence of a reflecting team where even body language became important in that it was not just what was said, but how it was said (Flaskas, 2011). Rather than developing a defined model, it became a therapy of what worked (Flaskas, 2011). Dialog is the first thing a newborn infant takes a part and learns. People relate to each other and their own selves through dialog (Seukkula, 2011). When dialog was first considered in the 1980s, the focus was upon the spoken dialog, the words which were said (Seukkula, 2011).

Through time and experience, the therapy moved away from the psychiatric setting which has allowed the polyphonic presence, the many voices of dialog, to be more important than the words themselves (Seukkula, 2011). Psychological resources are brought to light in and for both the individual member of the family and the family as a whole (Seukkula, 2011). The therapist must be aware of and partaking in what is occurring, taking it in and responding to the dialog’s every expression and living in the moment as a phenomenon occurs which is as inexplicable as it is invisible and yet present (Seukkula, 2011). In that moment, no one is wrong, and all should be given voice and place with the exception that no one should interrupt or speak over another (Seukkula, 2011). The challenge is to give up one’s own goals as a therapist and live in the moment of the client’s dialog – listening, hearing, and understanding while taking it seriously with concern and compassion; thus a relationship is built in the dialog, following the client’s language and lifestyle (Seukkula, 2011). The therapy is not in the therapist translating, but in the therapist gaining an understanding of the linguistic expression by moving from highly specialized knowledge to implicit understanding of what happens is life so that even the words are not known before becoming aware of the moment (Seukkula, 2011). The moment is akin to  parents’ interchanges with their infant child – no legible words are needed, but they respond to each other in a mutual emotional attunement by facial expression, hand movements, and vocalized tones; the child responding to the parent with coos while the parent is responding to the child with stimulating and encouraging expressions as emotions flow in a circle between the two (Seukkula, 2011). Healing occurs in the dialogue by allowing the client to not just talk but to be heard, to have peace when the response is given and received. Then the therapeutic process has been drawn to completion (Seukkula, 2011).

Systemic-Dialogical Therapy

With the discussion of systemic-dialogical therapy (SDT), dialogical therapy is brought into what some may see as an oppositional contrast to systemic therapy (Bertrando & Lini, 2019). Systemic therapy follows the guidelines of hypothesizing, circularity, and neutrality which is unlike dialogue with its constant interchange (Bertrando & Lini, 2019). While systemic therapy traces it origins through the order of systems theory, that order was non-specific in that location was not specified and was undefined; it was therefore questioned (Bertrando & Lini, 2019). Into this came a Russian philosopher and narratologist, Mikhail Bakhtin, who saw dialogue as the basic human condition and in discourse he saw a plurality of languages and positions which became known as dialogism (Bertrando & Lini, 2019).  Seikkula read Bakhtin’s work in Russian not long after it was published in the 1980’s and was influenced by him (Seukkula, 2011).

Bertrando and Lini describe dialogism having two key aspects, the first being that of polyphony (a multitude of voices, persons, or characters in a dialog) and the second as being heteroglossia in which several languages coexist within a person where each are social and historical compilations(2019). In the application of dialogism, clients are continually developing with dialogues that cannot be predicted and thereby creating a polyphony; this certainly differs from systems theory’s categorizing by definition and category (Bertrando & Lini, 2019). Life is then unordered and constantly in flux as it relates with society and the dialog brings the person into existence so therefore the dialogical approach is the best approach in therapy (Bertrando & Lini, 2019).

Integrating the systemic framework with dialogical therapy, done through in-depth investigation of their basic premises and addressing contextual and positioning issues, will contribute to the emergence of a new practice model of systemic-dialogical therapy (Bertrando & Lini, 2019). This allows a better understanding of the positioning of clients and therapists in therapy (Bertrando & Lini, 2019). Heteroglossia is pursued by encouraging spontaneous and open communication among the participants (Bertrando & Lini, 2019). The therapist participates by listening and questioning without expecting an answer while seeking to find the position from which to help the clients assume responsibility for their choices and decisions in life (Bertrando & Lini, 2019). Emotions are a significant part as they come in response to another’s emotion and both the obvious and hidden are regarded by the therapist (Bertrando & Lini, 2019). Small hypotheses or mini-hypotheses are a continual part of the process by the therapist as emotional events are observed and used to relate to other elements in the dialog and to stimulate connections between their own feelings and relationships (Bertrando & Lini, 2019). The position of the client can be viewed as that of being entangled in a network of systemic processes which are held together by continual dialog; systemic-dialogical therapy then occurs by encouraging a widening of the dialogs so the client can grasp a new perspective from which to continue their own dialog in amity with their former troubles (Bertrando & Lini, 2019).

Conclusion

There are several commonalities in some of the major frameworks of family therapy as it is currently practiced including strengths framework, the influence of systems theory, dialogue, relationships, and the therapist’s position. An overarching strengths framework carries the main burden of family therapy with clients encouraged to discover intrinsic psychological resources and strengths through which they can come to terms with their presenting challenge. By focusing on what is right with the clients, their confidence is built so that greater strides may be made toward the solution. The influence of systems theory continues even in dialogical theory as everyone is honored as uniquely important and a relationship is built. The client is afforded a safe place in all in which to freely express emotions, vocalizations, and ideas. All of these considered therapies focus upon the importance of the relationship and in dialogical and system-dialogical therapy the relation is acutely important since the clients are certainly aware of the therapist’s levels of concern and respect toward them. All therapies require strong listening and linguistic skills – essential dialog skills. Dialog itself is so very important in the world of psychotherapy in that through voicing one’s concerns, emotions, and inner dialog one can find one’s own strength and personal resources which are innate and capable of handling the problems of life. The therapist assumes a similar position in each of these in that they are no longer the expert, but place themselves with the context of the clients, collaborating with the clients and allowing the clients to be their own experts. All these theories are pragmatic in that they seek for utility without regard for credit.

Family theories started as a bold step perhaps in response to psychoanalysis’s lack of results and has progressed through many changes from a point of a unified front to having many various and varied models, theories and frameworks. It seems to have now come full circle in that is again appears to a unified front, but with a much a much larger toolbox – perhaps even a large roof over many basic and widely used ideas and theories. These common goals, theories, models, therapies, terminology, and frameworks work to strengthen family therapy, and will no doubt continue to grow and impact this complex world of human social relations. Ultimately, it will be the therapist attentiveness to the needs of the client in choosing the best framework for each client in choosing the best framework for each client and their families. With the available “tools” there is a flexibility that can be shaped to fit the presenting need.

References

• Bertrando, P. & Lini, C. (2019). Theory and practice of systemic-dialogical therapy. The Australian and New Zealand Journal of Family Therapy, 40(2), 210-222.                     doi: 10.1002/anzf.1365
• Bruenlin, D.C. & Jacobsen, E. (2014). Putting the “family” back into family therapy. Family Process 53(3), 462-475. doi: 10.1111/famp.12083
• Choi, J. (2019). A microanalytic case study of the utilization of ‘solution-focused problem talk’ in solution-focused brief therapy. The American Journal of Family Therapy, 47(4), 244-260. doi: 10.1080/01926187.2019.1637302
• Ember-Black, E. (2014). Eschewing certainties: The creating of family therapists in the 21st century. Family Process, 53(3), 371-379. doi: 10.1111/famp.12091
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• Franklin, C., Zhang, A., Froerer, A., & Johnson, S. (2017). Solution focused brief therapy: A systematic review and meta-summary of process research. Journal of Marital and Family Therapy, 43(1), 16-30. doi: 10.1111/jmft.12193
• Hardy, N., Brosi, M.W., & Gallus, K.L. (2019). Integrative systemic therapy: Lessons on the collaboration and training for the 21st century. Journal of Marital and Family Therapy, 45(2), 206-218. doi: 10.1111/jmft.12332
• Lorås, L. (2018). Systemic family therapy competences in child and adolescent mental health care. Contemporary Family Therapy, 40, 1-9. doi: 10.1007/s10591-017-9440-z
• Seukkula, J. (2011). Becoming dialogical: Psychotherapy or a way of life? The Australian and New Zealand Journal of Family Therapy, 32(3), 179-193. doi: 10.1375/anft.32.3.179