Systems of Psychotherapy: A Transtheoretical Analysis Chapter 11 – Systemic Therapies

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

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

Multiple Meanings of Systemic Therapies Therapy modality or format Treatment content or goal Paradigm shift

Three Systemic Therapies Communication/strategic therapy Structural therapy Bowenian therapy

Communication/Strategic Therapy 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

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

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

Theory of Therapeutic Processes Help individuals and systems to communicate clearly & constructively Changing communication changes relationships and power dynamics

Processes of Change Consciousness raising: aware of rules for communicating and relating Choosing: straight directives and paradoxical techniques Catharsis: Satir’s emphasis on feelings Counterconditioning: Haley’s emphasis on power and ordeal therapy

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

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

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

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

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

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

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

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

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

Bowen’s 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

Bowen’s 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

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

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

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

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”