When should we use family therapy?
Family therapy is indicated when a change is desired in the way a family functions. That might seem simple enough but families rarely come complaining of the way they function. Usually someone comes, or is brought, with particular symptoms or behavioral problems. The psychologist or therapist must then decide which therapeutic option, of the wide range which exist, will best meet the needs of the persons seeking help. Since change in any one family member inevitably has its impact on the whole family group, it is important to determine whether we should be working with the whole family, with a part of it, or just with one member. It is individuals that change, and change in the family system is a result of the changed behavior of the individuals in it. Intervention in the system, which is the basis of so much family therapy, is not always the best way of promoting change. With this in mind, family therapy can be a powerful treatment when properly used in the right cases. However, it should only be embarked upon after careful consideration of the relative merits of the full range of available treatments.
Family therapy should be considered when: (1) there is a malfunctioning family group; and, (2) the problems which therapy is to address are related to the functioning of the family. It is likely to be of value when the presenting problems concern children or adolescents; when families present complaining that members have problems in relating to each other; and when a family appears to be having difficulty making the changes required to pass from one developmental stage to the next for example when adolescents start to become more autonomous. Family therapy is neither a "cure-all" nor a treatment of last resort, but an effective way of dealing with problems which are embedded in a troubled family system. It may often be usefully combined with treatment of individual family members.
What is the goal-setting process in family therapy?
In work with families, there are at least four levels of goal setting. Each individual within the family has certain personal goals and hopes, and the family unit definitely has certain group expectations regarding what it wants to experience. The third goal-setting level is the community at large. Often dealings at school or work, for example, can be improved through the accomplishment of goals set at the family level. Therapist goals and expectations comprise the fourth level.
One of the more important principles to keep in mind is that the family is the major system that simultaneously works for individual autonomy or development, as well as for group or family solidarity. The two major developmental goals the family group has are: (1) helping its individuals to be competent and somewhat independent, while at the same time (2) maintaining links and commitments to the family as a whole. On the surface this seems like a contradiction. However, one of the major successes of family living is to learn about how to be part of a group and at the same time be separate from that group. Many families have difficulty achieving this balance. Either they emphasize family solidarity to such an extent that individual members have to relinquish their autonomy, or they emphasize individual autonomy to such an extent that there remains no family commitment whatsoever. Very often, the difficulty in balancing between these two poles, individual autonomy and family solidarity, underlies the problems that families in therapy experience. In the early phase of family work, the therapist has to help the family articulate their goals.
Symptom relief is one of the major goals a family wishes to achieve in the therapy situation. Symptom relief is the elimination or alleviation of the problem being experienced with one of the family members. It is very unusual for a family to enter therapy with the understanding that family change or some change in the structure of the family is desirable. The usual complaint, for example, is that Johnny is acting up and the family is having trouble controlling him, or that Dad is drinking and it's very disruptive to the family. In any case, the family usually puts forth one of its members as the problem and states that the primary goal is to make that problem go away. The job of the family therapist is to help the family develop additional goals in order to expand their perception of the problem to a group-interactional level. Psychological problems, in other words, need to also be understood in relationship terms. To accomplish this additional goal setting, the therapist must first help the family get a better composite view of their stated problems. This is achieved by asking each member to elaborate upon how he or she sees the problem. This process quickly illustrates how differently family members perceive the problem. It also provides an opportunity for each member to give voice to related difficulties, thereby bringing additional goals into focus. The following case example highlights how family goals can be broadened:
Mrs. W called for an appointment because she was concerned about her 18-year-old sons's behavior. She explained that he was acting irresponsibly, could not be depended upon or left alone in the home, and at times frightened other members of the family. She went on to explain that she had taken total responsibility for her sons since her husband was seldom at home and did not seem to care much what was going on in the family. She said that there were two other children in the family who were much younger than her son and presented no difficulties whatsoever. In fact, her concern was that her oldest boy's behavior would have disastrous effects on the two younger, good children. She thought that only her 18-year-old son should be seen in therapy, since he was the "problem." However, these parents consented to having the whole family come to the first session, after it was explained that it was important to get all the family members' ideas about what was going on. The first session began with asking each member of the family to explain why he or she was there. The father saw the under-involvement with him. The mother saw the problem as irresponsible and bizarre behavior on the part of the oldest boy. The oldest boy saw the problem as lack of communication and consistency between the parents. The two younger children were unaware that there was a serious problem in the family. It became quite clear to the family that they saw the problem in different ways and that they were all being affected by the problems differently. One of the more interesting features of the first session was the way the mother changed her perception of her husband. She had initially been adamant in her belief that her husband would not come to any of the sessions, and was shocked when he had agreed to attend. When first asked what her reaction was to having her husband there, she responded that she didn't think he would be involved or concerned. The husband responded by saying he was surprised at her reaction. He went on to say that he didn't show more concern because of his wife's involvement with the children and his belief that she didn't want him to be more involved.
This example illustrates how each member of the family has a different goal based on individual understanding of what is happening in the family. If a therapist were to set goals with any one member of the family or, for that matter, any two these goals would be different from those of the excluded members. Goal setting should be a process which involves all members of the family and should respect the fact that each member of the family might have some goal which is different from the other members' goals. These goals must be considered along with those set for the family as a unit.
Another issue in goal setting concerns short-term and long-term goals. For example, one of the major goals in the initial session is for the family to experience a safe environment where no one feels solely responsible for what is going on within the family. However, the therapist also develops goals for the total therapeutic endeavor. These goals encompass some significant behavioral pattern changes within the family. Generally, the major long-term goals in family therapy involve helping families to: (1) improve communication; (2) feel accepted as individuals; (3) release the problem-bearer from this role; (4) develop more flexible assumption of leadership by any family member as circumstances require; (5) improve empathy and understanding; (6) improve ability to deal with and accept differences; (7) improve individual and family problem-solving abilities; (8) decrease the need to use scapegoats; (9) develop improved observational capacity among members concerning the internal functioning of the family; (10) improve autonomy and individuation; and, (11) develop a balance between individual autonomy and family solidarity.
Goal setting in family therapy, then, is connected with the stage of work of the therapy itself and the developmental stage of the family. Without a family problem, the therapist would not be invited into the family. The problem that the family presents with should always be taken seriously. Yet, how the family problem is dealt with or what emphasis the therapist puts on the problem will determine just what types of goals and expectations the family develops. How the therapist defines the problems is based on his or her theoretical framework for understanding family behavior.