Chapter 11 Family Therapy in the TwentyFirst Century

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Chapter 11Family Therapy in the Twenty-First
Century
Family Therapy in the 21st Century

• Nicole Flores

Nicole Flores
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Background

• From the radical experiments of the 1960s family
  therapy has grown into a very established force,
  complete with its own literature, organizations,
  and legions of practitioners.
• Today, the field has grown up, family therapy is
  no longer separated into different schools and
  its practitioners no longer share a universal
  adherence to the systems theory.

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Boundaries

• The boundaries between schools of therapy began
  to blur in the 1990s and no longer were
  therapists classifying themselves solely as a
  Bowenian or structural therapist.
• One reason
• -Gained experience, individuals began to borrow
  from other fields and make their own.
• -The need for individualization, if one family
  didnt fit into one model they weren't the
  right treatment case. Today there is no one size
  fits all
• Today therapists approach families not as an
  expert that is going to fix them, but as partners
  using all their resources to address the issue.

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Postmodernism

• Advances in science at the beginning of the 21st
  century allowed us to see that the truth of
  things could be uncovered through objective
  observation and measurement. The universe was a
  mechanism whose laws awaited discovery and once
  we knew these laws we could control our
  environment. This modernist approach influenced
  family therapists to approach their clients as
  cybernetic systems that are to be decoded and
  reprogrammed.
•  
• Walter Anderson Most of the conflicts that tore
  the now-ending modern era were between different
  belief systems Putting truths against each
  other, in FT this was structural truth verses
  psychodynamics Bowen versus Satir.
•  
• As the world shrank and we were exposed to
  different cultures, i.e. feminism, and gender,
  we had to reexamine our previous assumptions.
  Everything in our world was questioned,
  deconstructed and then reconstructed.

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The Feminist Critique

• Family Therapys rudest awakening.
• Exposed gender biases in models and treatments.
• Advocated style of therapy and called systems
  theory, and cybernetics into question.
• Blaming the victim and rationalizing the status
  quo
• Dealt with crimes against women such as
  battering, incest, and rape.
• - Long standing theories have been to imply that
  the women provoked their own abuse.
• Fighting the stigma that the fathers lack of
  involvement contributed to the mothers over
  involvement and the so called problem child.
• Solution- bring in father.
• Reorganize family so that no one is stuck in
  specific positions.

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Feminist Therapy!

• Designed to help women and men reexamine the
  gender roles that keep them from realizing their
  full potential.
• Helping each gender feeling intimate, expressing
  desire, feeling masculine, feminine, and
  powerful.
• Can be applied to various schools of FT but a
  big debate
• Feminism as it applies to therapy has less to do
  with clinical methodology than with thinking
  about which belief systems are holding certain
  problems in place.
• Fem. T is more like a worldview, taking into
  account the pervasive influence of gender and how
  it operates on our lives.
• Address financial issues between genders as well.
  
• Focusing on empowerment!!

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Social Constructionism and the Narrative
Resolution

• Constructivism was the lever that pried FT away
  from its claim to objectivity. Instead of
  focusing on family patterns of interaction,
  focusing on exploring the perspectives that
  people have with the interaction.
• Collaborative therapists were united in their
  opposition to the cybernetic model and its
  mechanistic implications.
• Their version of postmodernism focused more on
  caring than curing, moving the therapist out of
  the position of expert and more into a
  partnership with the clients.
• Reflecting team-used for advice in the
  collaborative models therapy- Creates open
  environment where the family feels like a team
  and the team feels more empathy for the family.

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Social Constructionism and the Narrative
Resolution

• Therapists do therapy with them not to them
• Authoritarian attitude vs. a position of not
  knowing leading to genuine conversations. Reflect
  and offer ideas and opinions.
• Constructivism focused on how individuals create
  their own realities hence, the post-modern
  psychology social constructionism.
• Emphasized the power of social interaction in
  generating meaning for people. Shifting the focus
  of therapy from action to cognition and took FT
  by storm in the 1990s.
• Narrative therapy-experiences generates
  expectations and expectations shape experience
  through the creation of organizing stories.

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Family Therapys Answer to Managed Care

• Solution-Focused Therapy was a new model that
  rose to popularity in the 1990s.
• Main goal was to get clients to shift from
  problem talk which is trying to understand
  their problems to a more solution talk which is
  focusing on whats working as quickly as
  possible. During this time agency budgets were
  getting slashed and managed care dictated the
  number of sessions for which practitioners could
  be reimbursed. This created a huge demand for
  this easy-to-apply approach.

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Family Therapys Answer to Managed Care Cont.

• Family Violence
• Systematic views family violence was the outcome
  of cycles of mutual provocation, an escalation of
  the emotionally destructive behavior that
  characterizes many marriages. Family therapy
  brought this into focus and called it what it is
  domestic violence and a very severe health
  concern that needs to be addresses.
• Multiculturalism
• FT has shown to embrace all ethnicities, learning
  to respect families of other cultures that have
  their own valid way of doing this.
• FT is making an effort to become more diverse.
• Advance over ethnocentrism but pluralism is a
  better term because it implies more balance
  between ethnic identity and connection to the
  larger group.
• If you dont know ask. 
•  

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Family Therapys Answer to Managed Care cont.

• Race
• Family therapy for many years ignored people of
  color but FTs like Nancy Boyd-Franklin and Ken
  Hardy brought race out of the shadows and forced
  it into the fields consciousness.
• Poverty and Social Class
• Economic disadvantage is related to the ethic of
  self-reliance that people are responsible for
  their own success, if you are poor it must be
  your own fault.
• Therapists need to educate themselves to the
  social and political realities of being poor in
  the United States.
• The economy has built in disparities to make it
  difficult to climb out of poverty. Now family
  income is decreasing, mortgages, energy costs,
  tuition are all going up. The therapist should be
  sensitive to the role financial pressures play in
  the lives of their clients.
•  
• Spirituality
• Important to explore a families spiritual beliefs
  without prying or scoffing. Peoples answers to
  those larger questions are intimately related to
  their emotional and physical well-being.
• Gay and Lesbian Rights
• After a long period of neglect FT in the late
  1980s began to face this discrimination. However
  despite major advancements in our society gays
  and lesbians still face discrimination and
  violence.
• The therapist needs to get as much information as
  they can about the identity, relationships and
  issues these individuals face.

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Tailoring Treatment to Populations and Problems

• Literature has changed, now no longer tied to any
  one school.
• Began to focus on how to do FT with a host of
  specific types of problems and family
  constellations.
• Personalizing the problem to the individual
  and/or family.

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Single-Parent Families

• Similar problem as in two-parent families-
• Overburdened mother enmeshed with kids,
  disengaged from adult relationships.
• Goal of therapy
• Strengthen the mothers position in relation to
  her children and help her become more fulfilled
  in her own life.
• Support the parent and focus on her sources of
  support
• Not underestimate the impact of poverty on the
  parents depression, self-esteem, independence
  and the decisions they have made about putting up
  with abusive relationship and bad jobs.
• Recognize the financial hardships and make
  accommodations for the parent s work schedule
  and career choices.
• Facilitating supportive connections and reducing
  conflict, and develop alliances.

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Single-Parent Families Cont.

• Check involvement of the father- is he abusive?
  If not reach out to them and incorporate them
  into the lives of the children.
• Showing how to interact with their children as
  parents rather than as friends.
• Live-in partners can be seen as another form of
  support for both the parent and the child. But be
  careful to not over discipline their children
  that is not their role or their job.

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African American Families

• Therapists should be ready to expand the
  definition of family to include an extended
  kinship system.
• This network is one of the keys to coping with
  the pressures of oppression.
• Therapists job is to find others in the family
  or kin that can help with support but the family
  line can become blurred.
• Example of Deana and Juanita pg 321.
• Religion and spirituality provides both real and
  potential resource, gaining strength from the
  church community.
• One reason for father-absent households- there
  are far fewer men than women in the black
  community, therapist needs to keep the father
  involved with the family
• Absence of black men are infant mortality rates
  double that of whites, an epidemic of substance
  abuse, death related job injuries and reluctance
  in seeking health care

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Gay and Lesbian Families

• Suffer from the same problems as any long term
  couple.
• Need to learn to balance time tougher.
• Discuss if they want to have children, if so who
  will be the biological parent.
• Coping with homophobia in society and in their
  families, decisions about being out
  professionally or only socially.
• Therapist cant ignore or exaggerate the unique
  nature of same-sex parings.
• The therapist needs to deal with homophobic
  issues within themselves, one who is anxious
  about working with this couple may not give them
  the appropriate help they need or ask the
  important questions necessary to make appropriate
  assessment.

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Gay and Lesbian Families Cont.

• Client self-loathing, negative images of
  homosexuality and same sex relationships. Many
  stigmas are that gay relationships are unstable
  and hard to maintain.
• Sensitivity to the internalization of traditional
  gender norms.
• Therapist needs to ask questions about monogamy,
  finances, household duties, jealousy and coming
  out.

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HomeBased Services

• A decent of the friendly visitor movement
• Back in the day, social workers would call on
  families in their homes and may remove children
  out of a harmful situation.
• Now there has been a huge effort to keep even
  fragile families tougher and prevent placement of
  children.
• Home-based services target the family as the
  primary recipient of mental health care.
• Unlike conventional models the home-based
  approach focuses more on expanding the network of
  a familys resources than on repairing family
  dysfunction.
• A collaborative mind-set and positive
  expectations this is a strength-based approach.
• Agencies are viewed not as adversaries but as
  potential partners in the treatment process.

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HomeBased Services Cont.

• Includes Four elements
• 1-family support services -help with food
  clothing and shelter.
• 2-therapeutic intervention- may include
  individuals family, or couple treatment.
• 3- case management- involves developing links to
  community resources i.e.. Medical care,
  education, welfare, job training etc.
• 4-crisis intervention- making available 24 hour
  emergency services, wither with the home-based
  agency or by contracting with an outside mental
  health emergency.
• If there are other agencies with the family then
  learn how to collaborate with them.
• Dealing with the family in the home may draw the
  therapist into their problems in a more direct
  way than the therapist is used to

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Medical Family Therapy and Psychoeducation

• Over the past 15 years this approach has changed.
  Rather than solve problems, the goal of this
  approach is to help families cope with
  disabilities.
• Psychoeducation therapy emerged from working with
  schizophrenic patients and their families.
• Medical family therapy developed from healing
  families struggle with chronic illnesses such as
  cancer, diabetes and heart disease.

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Psychoeducation and schizophrenia

• A search for the cure for Schizophrenia launched
  the field of family therapy in the 1950s.
• Today we know that Schizophrenia involves a
  biological origin that is unknown.
• Family therapy and psychoeducation is considered
  part of the most effective treatment for this
  disorder.
• The psychoeducation model was born from a
  dissatisfaction with traditional family therapy
  and psychiatric approaches.
• In the families of schizophrenia there is usually
  criticism, hostility, emotional over involvement
• This concluded was a high EE (expressed emotion)
  house hold.

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Psychoeducation and schizophrenia

• We know now that schizophrenia is a thought
  disorder that renders individuals particularly
  sensitive to the expression of criticism and
  hostility.
• Theory- intense emotional input makes it
  difficult for patients to cope with the chaotic
  thoughts.
• It is necessary to reduce EE in helping families
  cope with schizophrenia and lowering EE has been
  shown to reduce relapse rates for major
  depression and bipolar disorder.
• In the 1970s therapists were experimenting with
  two ways to reduce stress (1970) one was the home
  environment of their parents home.

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Psychoeducation and schizophrenia

• Goldstein Model (1978) UCLA- focused on
  anticipating the stresses a family was likely to
  face and then reducing conflict around the
  patient.
• Others followed suit, (Ian Falloon and Carol
  Anderson). Andersons model looks similar to
  structural family therapy except the families
  structural flaws are considered as the result,
  rather than cause of the presenting problem.

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Psychoeducation and schizophrenia

• Psychoeducators try not only to help families
  change their ideas about and interactions with
  patients but also try reverse the damage done by
  insensitive professionals.
• Seek to establish a collaborative partnership in
  which family members feel supported and empowered
  to deal with the patient.
• Reeducate professionals to give up the idea that
  the family is responsible for the
  schizophrenia/reinforce strengths/ help family
  develop a sense of mastery.
• Lower expectations, reduce pressure on patients.

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Medical Family Therapy

• Work with families struggling with illness or
  disability, similar to schizophrenics.
• Help deal or prepare for illness.
• The system-
• The sick and their family, the doctors, the
  nurses work in collaboration with all.
• Goal-
• Foster communication and support for all.
• Combat feelings of helplessness and confusion.
• Families need to explore their options
• 1990 this part of the field took flight now it is
  called collaborative family health care

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Relationship Enrichment Programs!

• This wonderful thing called psychoeducation has
  also been applied to couples and families!
• Self-help!!
• Marital enrichment programs!!! YAY!
• The guru of this field is Bernard Guerney, Jr.
• He and other facilitators currently teach
  participants to clarify their conflicts, then,
  recognize and express what they are feeling,
  accept each others feelings, negotiate and work
  through problems. Learning to achieve
  satisfaction by becoming emotional partners!

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Relationship Enrichment Programs!

• Relationship enhancement programs provide couples
  with three skills
• The expressive skill-(owning) gaining awareness
  of ones own feelings and taking responsibility
  for them with out projecting onto others.
• The empathic responding skill-(receptive)
  learning to listen to the other persons feelings
  and motives.
• The conversive skill-(discussion-negotiation/engag
  ement ) learning to acknowledge the meaning of
  what was heard, partners may switch positions
  between listener and speaker.

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Discussion Qs!

• Constructionism-Is moving the therapist out of
  the expert and into the partner role, always
  a good idea? And when can it go wrong?
• Does the Feminist theory work for every problem?
  And what type of problem would be best to use the
  approach?
• What common trend do you see through out the
  chapter that is common to other chapters in the
  book?