Work With Families

1
Work With Families

• Step Six of the Decision Tree
• Chapter 14 Family Therapy

2
Two Models of Social Work With Families

• Content on work with families is frequently
  placed in second year curriculum as an optional
  specialization in direct practice (MSW)
• When family is the method of choice (step six)
  two different practice models exist.
• One model is focused on service delivery
  financial assistance and protective services. See
  chapter 15.
• The other model is focused on family therapy. See
  this chapter.

3
Criteria For Choosing A Method of Therapy

• When therapy is the treatment decision, clinical
  social workers may choose individual, family, or
  group therapy.
• Each method of therapy requires specialized
  knowledge.
• Each method has a different skill set and
  different conceptualizations of the worker-client
  relationship, how to formulate what is the
  matter, and how to enact the therapeutic process.

4
Selecting Family Therapyas the Method of Choice

• Family therapy is the method of choice when
  families deal with the ordinary problems of
  family life (family life cycle).
• It is the method of choice when families
  encounter predictable and unpredictable life
  stressors
• It is the method of choice when improvement in an
  individual family member will not occur or be
  sustained without changes in family structure and
  patterns of family interaction.

5
Differentiating Family Therapy From Individual
Therapy

• Individual therapy is based on linear causality
  family therapy is based on mutual causality.
• Prior to General Systems theory, the major focus
  in the behavioral sciences was on individual
  functioning as reflected in psychodynamic theory,
  classical behaviorism, neo-behaviorism and
  learning theory.
• The goal of intervention in linear models is to
  restore normal functioning through interventions
  that biological, cognitive or psychological.

6
Linear and Mutual Causality

• Linear causality holds that behavior is
  biologically determined (genetics) or reactive
  e.g. determined by early childhood experiences or
  on antecedent (S-R) or consequent (reinforcement)
  events.
• Mutual causality holds that behavior is multiply
  determined. Therefore the focus of functioning
  shifts from the individual to the (family)
  system.
• Individual problems are redefined as flawed
  familial structures and flawed patterns of family
  interactions.

7
Point of Entry to Family TherapyWho is The
Client?

• Index Person The point of entry to family
  therapy is usually through an index person (IP)
  who has been referred for help. Problem
  exploration indicates that family therapy may be
  the treatment of choice.
• Designated Help Seeker Alternatively, point of
  entry may occur when an adult (e.g. a designated
  help seeker, usually the wife/mother) seeks help
  for a member who has been identified by others in
  the family as in need of help.

8
Declarative KnowledgeFamily Therapy

• For purposes of this chapter, 4 theory-based
  practice models have been chosen to illustrate
  family therapy and to differentiate it from
  individual therapy. These models are (1) family
  systems theory,(2) family life cycle theory, (3)
  Bowens theory of differentiation, and (4) Haley
  and Minuchins structural-strategic theory.
• As a method, family therapy is more complex than
  individual therapy in that the clinician must
  focus on the family as whole and on each
  individual member in interaction with other
  family members.

9
Overview of TheoryGeneral Systems Theory

• General systems theory focuses on the
  transactional patterns between components of a
  system and on the transactions between one system
  and another.
• This theory accepts mutual causality e.g. that
  each component of a system impacts another and
  the system as a whole.
• Every model of family therapy adopts or shares
  system concepts but is, in addition, conceptually
  unique.

10
General Systems Theory Premises

• The major explanatory premises derived from
• General Systems theory are
• The whole is greater than the sum of its
• parts
• A change in one part of the system will lead to
  changes in other parts of the system
• Systems are dynamic not static therefore systems
  are in a constant state of flux
• Causality is complex

11
General Systems Theory Premises-Continued

• (5) Feedback is a method of controlling how
  systems
• function by inserting performance results
  that
• allow for correction change.
• (6) Systems must remain stable (homeostasis) and
• change (adaptability).
• (7) Adaptability is essential if a system is to
  avoid
• the forces of entropy (decay
  dissolution).
• (8) Morphostasis refers to structural constancy
  
• (9) Morphogenesis refers to change within
  stability

12
General Systems Theory Premises-Continued

• (10) Tension refers to the push to maintain the
• status quo (equilibrium) and the pull to
• change or adapt (disequilibrium).
• Family systems theory is a subcategory of
  General Systems theory.

13
General Systems TheoryConcepts

• General System theory (Bertanlaffy, 1968) is a
  theory found in many disciplines.
• A living system is defined as a complex of
  elements with interactions that are ordered
  (nonrandom).
• System is a concept used to differentiate it from
  a collection where the parts remain individually
  unchanged whether isolated or together.

14
General System ConceptsContinued

• A boundary is an invisible demarcation that
  separates one system from another. All systems
  have boundaries that identify it as a system.
• Negative Entropy is a concept that refers to the
  decline of energy and decay of a system
  associated with with a closed system and
  impermeable boundaries.

15
Model One Family Systems Theory

• When applied to families, concepts borrowed from
  General Systems theory are borrowed and refined.
• System is refined as supra-system, subsystem and
  focal system. The family is the focal system. The
  environment in which it operates is the
  supra-system and its members, in various
  combinations, constitute subsystems.
• Structure All families create a hierarchy of its
  subsystems parental subsystem, child subsystem.

16
Family Systems TheoryConcepts-Continued

• Function-All families create patterns of
  interaction whereby they carry out the necessary
  tasks of maintaining the integrity of the family
  system in order to keep it functioning.
• Boundaries-All families create boundaries that
  govern interactions within the family system and
  between the family system and those outside it.
• Boundaries may be semi-permeable, permeable,
  or rigid.

17
Family Systems TheoryConcepts-Continued

• Equlibrium (Homeostasis) All families must
  maintain equilibrium (stability) and adapt to new
  input (change)
• Feedback (input/output) Family therapists
  intervene to correct the course of the family
  system. Negative feedback brings a deviating
  family system back on course. Positive feedback
  exaggerates the deviation

18
Model Two Family Life Cycle

• This model combines concepts from General Systems
  Theory and from Psychodynamic Developmental
  Theory.
• This model holds that families seek therapy when
  stage-specific family or individual tasks get
  derailed progress to the next stage is blocked.
• Derailment may be caused by predictable,
  normative, individual and family developmental
  stages or may be caused by unpredictable life
  events.

19
Family Life CycleStages

• Carter and McGoldrick identify six family life
• cycle stages
• Launching the young adult
• The couple
• Families with children
• Families with adolescents
• Launching children and moving on
• Families in later life

20
Family Life Cycle Assessment Stage One
Derailments

• Stage one- the single young adult must separate
  from her/his family of origin without cutting off
  or fleeing.
• Derailment occurs when families dont let go of
  their adult children or the adult children remain
  dependent or rebel

21
Family Life Cycle AssessmentStage Two Derailments

• The task of this stage is to form a new family
  system separate and distinct from the couples
  families of origin.
• Derailment consists of enmeshment (failure to
  separate from a family of origin) or distancing
  (failure to stay connected).
• Couples may experience interpersonal difficulties
  in intimacy and commitment.

22
Family Life Cycle AssessmentStage Three
Derailments

• On stage three, the new family is tasked with
  becoming caretakers to the next generation
• Derailment at this stage involves couple, and
  parenting issues. Maintaining appropriate
  boundaries with both sets of grand parents may
  become an issue.
• Couples must work out a division of labor, a
  method of making decisions, and must balance work
  with family obligations and leisure pursuits.

23
Family Life Cycle AssessmentStage Four
Derailments

• In stage four, families must establish
  qualitatively different boundaries for
  adolescents than for younger children.
• Derailment at this stage is related to adolescent
  exploration, friendships, substance use, sexual
  activity and school
• Parents may face a mid-life crisis

24
Family Life Cycle AssessmentStage Five
Derailments

• The primary task of stage five is to adapt to the
  numerous exits and entries to the family system.
• Derailment occurs when families hold on to the
  last child or parents become depressed at the
  empty nest.
• Derailment can occur when parents decide to
  divorce or adult children return home.

25
Family Life Cycle AssessmentStage Six Derailments

• The primary task of stage six is adjustment to
  aging.
• Derailment consists of difficulties with
  retirement, financial insecurity, declining
  health and illness, dependence on ones adult
  children, the loss of a spouse or other family
  members and friends.

26
Family Life Cycle AssessmentPredictable and
Unpredictable Crises

• All individuals and all families go through
  predictable, normative developmental crises.
• In addition, individuals and families experience
  unpredictable crises e.g. job loss, illness,
  accidental injury
• Disruption in a family life cycle stage can
  interfere with individual development similarly
  disruption in an individuals life cycle stage
  can interfere with a familys life cycle
  development.

27
Family Life Cycle TherapyTherapeutic Process

• Therapy is perceived as helping families get back
  on the developmental life cycle track after being
  stuck or derailed at a particular stage.
• The therapeutic goal is progress from one
  developmental stage to another.
• Often a clinician works with a dyad
  (parent/child parent/adolescent) to help the
  dyad recognize (insight) and solve the
  derailment.

28
Family Life Cycle TherapyTherapeutic Process

• Usually the clinician does not work with the
  family as a whole.
• It is assumed that work with one part of the
  system will benefit the system as a whole
• Whether working with a dyad is more aligned with
  individual therapy or family therapy is
  controversial.

29
Model Three Bowens Family Therapy

• Bowens model is a blend of General Systems
  theory and Psychodynamic theory.
• According to Bowen, relationship patterns
  established in ones family of origin are
  predictive of relationship patterns in ones
  family of formation.
• Like the family life cycle model, the therapeutic
  process in this model involves a single
  individual rather than the entire family e.g. a
  change in one part of the system affects the
  system as a whole.

30
Bowen ModelKey Concepts

• Key concepts in this model are
  inter-generational emotional transmission,
  horizontal and vertical stressors, and
  individuation.
• Individual emotional health is tied to an inter
  -generational emotional field. Problems occur in
  families when the adults fail to differentiate
  themselves from their family of origin and
  recreate flawed emotional transaction patterns in
  their family of formation.
• The family is an operative emotional field that
  exists from cradle to grave.

31
BowenVertical and Horizontal Stressors

• Vertical stressors are emotional norms and rules
  transmitted across generations. Examples are
  family secrets, attitudes, taboos, labels,
  legacies, myths, loaded issues.
• Horizontal stressors refer to predictable
  (developmental crises) and unpredictable current
  events (life threatening illness, divorce, etc).
• Families may experience stress and anxiety when
  they experience vertical or horizontal stressors.
• Intersect family dysfunction is most likely
  greatest when vertical and horizontal stressors
  intersect.

32
BowenIndividual Symptoms

• Horizontal and vertical stressors impact family
  emotional transactions and individual symptom
  formation.
• Family dysfunction is viewed as a maladaptive
  emotional response to stress.
• A three generational genogram is used to visually
  depict emotional transmission across generations.
• Individual dysfunction reflects an active
  familial emotional system in need of correction.

• The goal of

33
BowenTherapeutic Process

• The goal of therapy is to help individual young
  adults emotionally differentiate themselves from
  their family of origin so dysfunctional emotional
  transactions do not get replicated in their
  family of formation separation and
  individuation.
• The therapeutic process often involves coaching
  an individual young adult to engage his/her
  parents in a new healthy way of relating.
• Another therapeutic process involves boundary
  adjustment separate but connected.

34
Model FourStructural-Strategic Family Therapy

• Premises
• According to this theory, a family is regarded as
  dysfunctional when it responds to internal or
  external demands in a way that reflects a flawed
  family structure or a dysfunctional pattern of
  interaction.
• An index persons symptom is perceived as a
  system-maintaining or system maintained device.
• Dysfunctional patterns result from stress and
  block healthy ways of relating.

35
Structural-Strategic Family Therapy Concepts
Structure

• Structure Hierarchy of family subsystems all
  members have roles (tasks and functions) in the
  family.
• Ecomap Pictorial depiction of the family in its
  environment (suprasystem familys formal and
  informal networks, neighborhood community.
• 4 major subsystems within families (1) spousal,
  (2) parental, (3) sibling, (4) individual

36
Structural-Strategic Family TherapyConcepts
Function

• Repeated transactions establish internal patterns
  of how, when and to whom to relate.
• The family system is maintained by a limited
  number of rules, implicit or explicit, the
  prescribe the rights, duties, and range of
  appropriate behaviors within the family.
• Patterns that are functional in one situation may
  not be functional in another situation.
• Familys develop preferred patterns of
  interaction are are resistant to changing them.

37
Structural-Strategic Family TherapyAssessment
Flawed Familial Structures

• Flawed Structures
• Parental-child structure child is allocated
  parental power in the family
• Parental-flux pattern of paternal leaving
• Father (or mother) is in and out of the
  family military service, job-related travel,
  incarceration
• (3) Familial stress family negotiates stress in
  one subsystem through other sub systems e.g.
  spousal difficulties are handled through child
  symptom formation.

38
Structural-Strategic Family TherapyAssessment-Con
tinued

• Flawed Structures
• (4) Family system boundary Boundaries are
• too diffuse or too rigid.
• Flawed Patterns of Interaction Assess
• Family routines
• Flow of information across boundaries
• Functional performance support, regulation,
  nurturance, socialization
• Task performance getting up, dinner time, chores
  etc.

39
Structural-Strategic Family TherapyAssessment

• Rules
• Explicit rules
• Bedtime at 1000 oclock
• Come home after school
• No profanity in this house
• Implicit rules Inferred from family Interaction
• Dad is always right
• Dont say what you really feel

40
Structural Strategic Family TherapyTherapeutic
Process

• Joining Therapist joins (use of self) entire
  family in sessions participant-observer in the
  family process. Therapist accepts responsibility
  for success/failure of his interventions.
• Probes Identify dysfunctional structures
• Probes trigger family transactions that are
• diagnostic.
• Directives Therapist uses directives to trigger
  family transactions that are either diagnostic or
  corrective.

41
Structural-Strategic Family TherapyTherapeutic
Process

• Pain management Therapist possesses skill to
  contain and manage family individual pain as
  introduces stress needed for family to change.
• Unbalancing Therapist aligns with one family
  subsystem against another to correct flawed
  structures.
• Boundary adjustment Therapist uses space
  (proximity/distance) to mark, create, strengthen
  or weaken boundaries.

42
Structural-Strategic Family TherapyTherapeutic
Process

• Tasks therapist assigns tasks to promote or
  decrease communications interactions among
  members.
• Mapping Is a diagnostic hypothesis of what is
  the matter and its goal directed solution. It
  suggests the technique to be used to achieve the
  desired outcome.
• Blocking Technique to restructure flawed
  subsystem. Workers use of self to block faulty
  transactions between family subsystems the IP.

43
Structural-Strategic Family TherapyTherapeutic
Process

• Reframing Worker strengthens subsystem
• boundaries by labeling (reframing) the
  behavior of the index person in positive terms.
• Paradoxical Interpretations Therapist offers
  explanation of behavior that is counter-intuitive
  e.g. viewing symptomatic or problematic behavior
  as healthy behavior used to benefit the family.
• Techniques of Structural-strategic family therapy
  change how members order their interactions and
  the purpose (function) of those interactions.

44
Critique of Family Therapy

• Cultural relevance These models are criticized
  for not being culturally relevant. Family
  structures and norms governing family behavior
  vary across cultures and within the same culture
  overtime.
• Bias These models depend on some definition of
  normal or functional. Critics charge that
  dominant groups have the power to define and thus
  categorize differences as pathology. Models do
  not address gender discrimination or alternative
  family structures.

45
Critique of Family TherapyContinued

• Ideology Definitions of family are
  ideologically- based. Values determine the
  conceptualization of family.
• Medical Model Critics charge that these models
  focus on deficits or symptoms rather than family
  strengths.
• Status Quo Family therapy is criticized for
  maintaining the status quo (power differential)
  instead of challenging discriminatory norms or
  practice that negatively affect families or harm
  individual members

46
Critique of Family TherapyContinued

• Romanticized Version Critics charge that family
  therapy holds a romanticized and ideological
  version of the family. The concept of family
  often masks violence (psychological and physical)
  toward women and children while it protects men.
• External Realities Critics charge that these
  models do not address the objective reality of
  racism, discrimination, oppression and poverty
  faced by many families.

47
Teaching Tools

• See exhibit 14.1 for an example of a family
  therapy process recording.
• See exhibit 14.2 for a decision schema to guide
  you in the use of selecting family therapy as a
  method and in selecting an appropriate
  theory-based model of family therapy.
• See chapter 15 for working with families in need
  of service delivery financial assistance and /or
  protective services.