Systems of Psychotherapy: A Transtheoretical Analysis

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Systems of PsychotherapyA Transtheoretical
Analysis
Chapter 11 Systemic Therapies
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The Context of Systemic Therapies

• Individuals can only be understood within their
  social context
• Contextless is meaninglessness
• Patient is the entire system, not the identified
  patient (IP)
• General Systems Theory cybernetics are the
  intellectual inspirations for systemic therapy
• Systems parts of an organization
  relationships among those parts

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Homeostasis

• Homeostasis or balance explains how living
  systems control steady state
• Feedback loops are the important control
  mechanisms
• Not linear cause and effect, but rather
  reciprocal effect
• Positive feedback loops set up runaway situations
  that drive systems beyond their limits
• Negative feedback loops decrease deviations from
  system rules

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Multiple Meanings of Systemic Therapies

1. Therapy modality or format
2. Treatment content or goal
3. Paradigm shift

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Three Systemic Therapies

• Communication/strategic therapy
• Structural therapy
• Bowenian therapy

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Communication/StrategicTherapy

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

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Theory of Psychopathology

• Psychopathology is a function of unclear or
  hostile communication
• Pathology is familys homeostatic mechanism to
  maintain system balance of
• Psychopathology occurs when rules of relating
  become ambiguous
• Unclear communication patterns make rules
  ambiguous

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5 Axioms of Communication

1. It is impossible not to communicate silence is
   ambiguous communication
2. Communication implies commitment and defines
   relationships both report and command elements
   
3. Relationships are contingent on how a
   communication is punctuated or ended
4. Communication is both verbal and nonverbal
5. Communications are symmetrical (either side can
   lead the communication) or complementary (one
   side leads)

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Theory of Therapeutic Processes

• Help individuals and systems to communicate
  clearly constructively
• Changing communication changes relationships and
  power dynamics

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Processes of Change

• Consciousness raising aware of rules for
  communicating and relating
• Choosing straight directives and paradoxical
  techniques
• Catharsis Satirs emphasis on feelings
• Counterconditioning Haleys emphasis on power
  and ordeal therapy

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Therapeutic Relationship

• Develop an atmosphere conducive to congruent
  communication
• Empathy and positive regard are important
• Therapist is in charge and in control
• Therapist uses direct and indirect techniques to
  control relationship

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Effectiveness of Communication/Strategic

• Not a lot of controlled outcome studies
• Effective in tx of substance abusers
• Uncertain effectiveness in schizophrenia,
  anxiety, psychosomatic disorders
• Paradoxicals are as effective as straight/direct
  interventions

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Structural Therapy

• Developed by Salvador Minuchin (1922 - )
• Created to treat delinquents as systemic issue
  rather then individual problem
• Initial focus on delinquency and anorexia nervosa
  
• Influential and pragmatic approach

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Structural Theory of Psychopathology

• Structural theory is more concerned with what
  maintains psychopathology than with its causes
• Historical causes cannot be empirically
  determined and cannot be changed
• Dysfunctional dynamics of the family system
  maintain psychopathology

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Boundaries

• An organized family has clearly marked boundaries
• Disengaged families have rigid boundaries
• Enmeshed families have diffuse boundaries
• Dysfunctional families respond to demands for
  change in pathological ways

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Structural Theory of Therapeutic Processes

• Goal restructure families to free members to
  grow and relate
• Changing family structure involves changing rules
  for relating and boundaries
• Consciousness Raising education, reframing
• Choosing or social liberation Minuchin as
  freedom fighter

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Therapeutic Relationship

• Therapist joins each member or sub-system of
  family
• Initial relationship involves empathy, warmth,
  and caring
• Once relationship established, therapist becomes
  authoritative leader
• Therapist challenges, blocks, disrupts
  homeostasis

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Effectiveness of Structural Therapy

• Reliance on clinical case surveys
• Few controlled studies
• Found superior to no tx and probably superior to
  individual tx for substance abuse, psychosomatic
  disorder, and conduct disorder
• Untested in tx of other disorders

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Bowen Family Systems Therapy

• Developed by Murray Bowen (1913 1990)
• Initially applied to schizophrenic families at
  NIMH
• Dramatically applied to his own family
• A cerebral and deliberate approach

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Bowens Theory of Psychopathology

• Differentiation of self is ability to be
  objective controlled about emotional issues
• Emotional illness arises when individuals are
  unable to differentiate from their families of
  origin (fusion)
• Fusion results in undifferentiated family ego
  mass
• Fusion leads to triangulation

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Bowens Theory of Psychopathology (cont.)

• The child closest to parents is most likely to
  develop pathological symptoms
• Emotional cutoffs are efforts to cope with
  unresolved attachments to families of origin
• Family projection process
• Multi-generational transmission process

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Theory of Therapeutic Processes

• Goal increase differentiation of self from
  family emotional system
• Detriangulate family members
• Change produced in one triad will cause change in
  all family triangles
• Consciousness raising
• Choosing

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Therapeutic Relationship

• Therapists do not allow themselves to be
  triangulated
• Maintain an objective I position
• Therapists act as models of autonomous,
  responsible, and differentiated behavior
• Therapists rely on observation and reason (not
  empathy) to understand family

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Practicalities

• Often work with spouses or with one motivated
  patient
• Central couple is most important
• Strong proponent of family of origin therapy for
  psychotherapists

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Effectiveness of Systemic Therapies

• 20 meta-analyses indicate couples family
  therapies are effective average ES .65
• Positive effects remain but taper over time
• Martial therapy tends to show higher effects than
  family therapy
• No difference in effectiveness among different
  systemic therapies
• No consistent outcome differences between
  individual and family therapy for now, a tie