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Family Systems Therapy

Summary and Keywords

Family systems therapy seeks to alter the structure or processes of a family for the purposes of reducing distress in one or more persons and improving the ability of the family to meet members’ needs. Building from a general systems paradigm, family systems therapy recognizes that family structures shift over time as they respond to members’ developmental processes and broader system demands. As members enter and exit or change capacity, and as external stressors arise, the family typically uses adaptive processes to demonstrate resilience. Family systems therapy is useful when the family struggles to adapt, or the adaptation strategy further stresses the family.

Multiple models of family systems therapies offer variations in intervention approaches but have common tenets. Major models include Ackerman’s early psychodynamics model, transgenerational models of family therapy, structural family therapy, strategic family therapy, and communications approaches to family therapy. Models vary in their recommended roles for the therapist, strategies for therapist and family, and the salience of immediate versus longer-term goals. Family systems therapies conceptualize family interactions as complex, reciprocal, open, self-organizing, adaptive, social constructionist, and meaning-making.

Family systems therapy also can be used with systems larger than families, such as schools or organizations, or to understand cultural phenomena. The field of marriage and family therapy has defined competencies for practice, training requirements, and licensure standards and established national and international professional organizations.

Keywords: family therapy, family systems, family intervention

Introduction

Family systems therapy is a category of approaches that seek to alter the structure or processes of a family for the purposes of reducing distress in one or more persons and improving the ability of the family to meet members’ needs. In this article, conceptual foundations underlying family systems therapies are explored. Multiple models of family systems therapy are examined, and applications to various service systems are explored.

Conceptual Foundations for Family Systems Therapy

Family Systems Theory

Family systems theories share a focus on the family as a key social unit in which the members’ behaviors are studied in the context of the family unit. The systems paradigm examines the behaviors of individual members of the family within their interactional contexts. Individuals’ behaviors influence and are influenced by the entire set of interactions that define the relationships among the members. Although behaviors may arise from internal psychological processes, they inevitably function within a history of interactions that shape the expectations of the meaning and impact of those behaviors. Family systems theory arose along with cybernetic models within multiple disciplines in the 1940s and 1950s (Goldenberg & Goldenberg, 2009). Behaviors of the members of a system were studied as parts of a whole, complex entity within which parts relate to each other in consistent, predictable, reciprocally influential ways (Stanton, 2009).

Evolving over the last half of the 20th century, the systems paradigm was applied to human families in a variety of ways that are retrospectively viewed as holding common tenets despite their distinctiveness during their earlier phases of development. Key systemic concepts include complexity, reciprocity, living open systems, self-organization, adaptation, and social constructivism and cognition (Stanton, 2009). The focus on complexity contrasted starkly with the dominant reductionistic paradigm of modern science. Explanations of behavior required examination of the position and function of the behavior in circular feedback loops of reciprocal influence. Mutual, interactive influences of behavior among members challenged linear explanations of causality, leading to a focus on circular feedback loops of co-constructed reality in the here-and-now. This view of the family as a living open system that interacts with its environment in patterns of mutual influence led to the recognition that family systems were self-organizing in ways that could promote adaptation. With a focus on how the family interacts rather than the content of the interaction, the systems approach shifted focus from individual experiences to the communication within the overall system.

In this paradigm, the members of the family system, and any professionals working with them, inevitably hold their distinct social constructions of reality such that no objective view could exist. Without an objective source of truth who can pronounce the correct way to view the family, the social constructionist framework allowed family systems therapists to join with the family as co-creators of new possibilities. Therapy addresses the role of cognition and communication in defining the family narrative in the present. The narrative or schema that shapes each individual’s behavior within the system can be rewritten or restructured to introduce the possibility of change in behavior among family members.

Simultaneous to the application of a systemic paradigm to families was a rapid change in the definition of family within Western culture. Among the many changes in family structures during this period were the increased prevalence of divorce, remarriage, cohabitation without marriage, gay and lesbian couples and families, and delayed coupling in young adulthood (Pasley & Olmstead, 2009). International perspectives on family structures and processes led to appreciation for even greater diversity in the meaning and application of the term family (Hong, 2009). Furthermore, the definition of family is influenced by the framework of the observer (Crosbie-Burnett & Klein, 2009) such that attorneys might define it as a legal entity whereas macro-economists would focus on the household as producer of goods and sociologists would focus on the family as a small social structure with defined roles, a shared past and future, and the site of specific human developmental activity (e.g., roles, births, deaths). The functions of families are generally defined as: “(a) support the physical development of members, including food, clothing, shelter, (b) educate and socialize children, (c) create an environment supportive of the sexual needs of couples, (d) care for the dependency needs of young, old, ill, and disabled family members, and (e) care for the human emotional needs for affiliation, belonging, and feeling valued” (Crosbie-Burnett & Klein, 2009, p. 39).

Family Development

Family development is reflected in changes over time in family structures and processes that are inevitable as family members proceed along individual developmental trajectories. The traditional life course conceptualization tracked families from the initial stage of couple formation, through child-bearing and rearing to the launching of children into adult relationships (McGoldrick, Carter, & Garcia-Preto, 2016). Each family life stage demands change in the family structure or processes as one or more members enter or exit the existing family structure (e.g., through birth, death, coupling) or change in substantive capabilities (e.g., school or adolescence). The stress of transitions creates vulnerability in families during which their capacities to adapt may be overwhelmed or their resilience may produce novel growth (Walsh, 2016).

The traditional family life course framework is problematic because it fails to account for variations in family structures that result from diverse pathways through adulthood. No universal sequence of life stages exists, due to the structural variations that occur as adults couple and uncouple, engage in marriage and divorce, blend children in stepfamilies, separate children into single-parent households, and form various relationship structures post-childrearing to adapt to added leisure time, new generations entering the family, and changes in functioning driven by health. Furthermore, the broader cultural context influences families differentially in their life cycle, as factors such as poverty, legal status of coupling or immigration, and the level of racism or sexism in the culture, among others, have profound impact on the family’s experience. In response to these critiques, McGoldrick, Carter, and Garcia-Preto (2016) broadened the framework to include multidimensional, multicultural, and multigenerational perspectives in the context of individual, family, and sociocultural variability.

Family Resilience

Family resilience refers to the adaptable skills of families in the face of significant stressors (Walsh, 2016). The Family Resilience Model (Henry, Morris, & Harrist, 2015) defines family resilience as the process that occurs when a “family risk interacts with family protection and vulnerability in ways that positive, rather than negative, short-term and long-term family adaptation occur at multiple family system levels” (p. 29). During times of stress, resilient families call upon strengths to apply their resources to their perceptions of the situation, thus restoring balance and mitigating the potential negative effects of the stressor on the family’s structure or processes (McCubbin & McCubbin, 1988; Patterson, 2002). Using multiple adaptive systems, families show resilience in unique pathways that are created when particular strengths address the context, developmental level of members, various risk and protective factors, and the family’s shared outlook (Hawley & DeHaan, 1996).

Models of Family Systems Therapy

Psychodynamic Models

Following Alfred Adler’s and Harry Stack Sullivan’s early modifications of psychoanalytic theory to include social contexts, Nathan Ackerman developed approaches to child psychiatry that focused on the family as a social unit (Ackerman, 1970). He viewed families as units of interacting personalities, each person operating as a subsystem within the family. Psychiatric symptoms within one member may have emerged from intrapsychic processes, but they impacted the family unit as a whole. The ways in which the family responded to the symptom could exacerbate the impact of the symptom on the individual and the family as a whole. Rigidity or chaotic processes in the family both undermined appropriate adaptation to changes within the family. Therapists joined the family, engaged members in emotionally meaningful interaction, and nurtured members. Family members could use the opportunity to gain insight into their own internal and interpersonal patterns as a basis for change.

Multiple other psychoanalytic and psychodynamic approaches address interpersonal functioning within the development of the self, within the therapeutic relationship, and within the family. Object relations theory was applied to families by early theorists (e.g., W. R. D. Fairburn) and was built into a systemic approach by Framo (1992). Framo’s therapeutic approach guided individuals, couples, and families to examine the internalized experiences from their families-of-origin. He developed a method of involving individuals with their families of origin to clear up old interaction patterns that were undermining current relationship functioning.

Transgenerational Models

Bowen’s Family Therapy

Murray Bowen (1978) extended psychodynamic concepts into a family systems approach by working closely with the emotional interchanges between couples, looking at the processes more than the content, and examining the impact of process on the family system as a whole. In particular, he emphasized the core processes that drew people to each other, and separated them. For Bowen, a core human challenge was the push and pull of family life through which families experienced the dialectic of family togetherness and individual autonomy. He postulated that humans have an innate push toward differentiation of self from the family of origin. However, the differentiation process unsettles and disrupts family linkages, especially in families with strong fusion processes. The key interpersonal processes were organized in triangles, the basic building block of the family emotional system. Because two-person systems were viewed as unstable especially under stress, the marital dyad tends to draw in a third party to diffuse growing tension and anxiety between them, thus distributing anxiety to that third party, whose psychological symptoms maintain the misdirected anxiety. Given the challenges of achieving differentiation of the self while sustaining meaningful connections to others, Bowen postulated a multigenerational transmission process by which anxiety is transmitted across generations through the mechanisms described.

Family Systems Therapy

Figure 1. Family genogram.

Therapy relies on family interviews to understand the structure and emotional processes of family dynamics. A genogram is developed to depict the family structures, and includes annotations about key information such as triangles, conflicts, and anxieties. As seen in Figure 1, genograms depict a partnership or marriage with a horizontal line, and offspring of that partnership are depicted with vertical lines descending from the partnership line. Scanning horizontally across a genogram, the relationships are within-generation, whereas scanning vertically tracks intergenerational relationships. Therapists function as coaches for parents or adults to develop strategies to handle interpersonal tensions within the immediate family or the family of origin, with the goal of improving management of anxiety and increasing differentiation of self to improve adaptiveness (Kerr & Bowen, 1988).

Contextual Therapy

Ivan Boszormenyi-Nagy developed contextual therapy to focus on transgenerational patterns of functioning through the lens of an ethical perspective. He explored the intersection of intrapsychic development with intergenerational issues related to rights, obligations, fairness, trust, loyalty, indebtedness, and entitlements. He and colleagues argued that a focus on proximal interactions within the family without appreciation of the impact of distal relational ethics in the current or previous generations cannot bring a healthy outcome (Boszormenyi-Nagy & Spark, 1973; Boszormenyi-Nagy & Krasner, 1986). Family legacies are handed down from generation to generation, and can be built within a generation, concerning expectations of family loyalties, responsibilities, and obligations. Within the metaphor of a family ledger, accounts are considered overdue or over-benefited for reasons that stretch over time, and that may not be understandable in the immediate interaction. Well-functioning families show flexibility in developing strategies for settling accounts, with individual autonomy being used to give to others in ways that balance the system. Therapists seek to increase individuals’ capacity for relatedness by enhancing the give-and-take in handling emotional aspects of the family’s ethical accounts.

Structural Family Therapy

As its name implies, the structural model of family therapy focuses on the ways in which family structures facilitate and impede functioning. The model postulates that structures that facilitate family functioning at one stage of the family life cycle may impede functioning at another stage. Symptoms in one member of the family are viewed as reflecting dysfunctional structures that require organizational changes to open opportunities for new ways of functioning that better meet the needs of family members and the overall operations of the family. Key areas of focus in this model are on the hierarchical relationships between parents and children, and the various subsystems that implement particular family functions. As the leading developer of the model, Salvador Minuchin built his intervention approach in the context of his work with disadvantaged families in New York and Philadelphia that spanned his career (Minuchin, Colpinto, & Minuchin, 2007).

Minuchin articulated the ways in which families form a set of arrangements that structure their interactions, often implicitly, into an organized whole that he defined as the structure of the family (Minuchin, 1974). Interactions illustrate the structure of the family, including its subsystems, permeability of the boundaries among subsystems, alignments, and coalitions. The structures are viewed as the scaffold through which families organize their interactions during life’s transitions due to member development or unexpected events. Interactions operate according to implicit (and sometimes explicit) rules that dictate how members are expected to behave. Members belong to multiple subsystems in complementary roles (e.g., parent-child; siblings; marriage/partner) that use rules to assign operating instructions and boundaries around the subsystem. Normal developmental transitions of family members provoke shifts in the rules and roles within subsystems to which the family organization as a whole must adapt. Family structures are viewed as dysfunctional if the organizational structure cannot meet the needs of its members.

The therapist joins the family system as a short-term member, and accommodates to its style in an effort to understand its structures, themes, and myths. After assessing the organizational structures and rules, the therapist seeks opportunities to engage the family in enactments of their conflicts within the therapy room, during which the therapist guides the family into a new resolution that illustrates a stronger family structure. The therapeutic intervention may involve changing the family rules, realigning members into subsystems that work better, establishing boundaries among subsystems, and reframing the meaning of the troubling situation by placing it into new contexts. These interventions involve therapists as directors of the family drama who use a theatrical flair to guide family interactions into new patterns that support structures that function far better for members and for the whole.

Communications and Strategic Family Therapy

Communications family therapy and strategic family therapy have close theoretical ties and shared influence between philosophical foundations and implementation of theory in practice. The Bateson Project of the 1950s that researched families of patients with schizophrenia laid the theoretical foundation for examining patterns of communication and family level outcomes. Although the original hypothesis that family communication was a cause of schizophrenia has been discredited, the communication family therapy frame developed in that project provided a groundbreaking way to examine reciprocal patterns of influence and outcomes within families.

The Communication Hypothesis

Aligned with general systems theory, cybernetics (study of regulatory systems), and information theory, communications theorists emphasized that there is no such thing as a singular message, as all communication is preceded and followed by nonverbal, verbal, and behavioral interactions that either support or contradict the preceding message. In addition, the recipient of the message interacts with the sender of the message and creates personal meaning (also known as punctuation) of the received message, which thereby serves to reinforce patterns of interaction due to interpretation, response, and circular interaction. Communication is experienced on multiple levels; for example, while a verbal statement is a form of communication, the tone of voice, facial expression, and relational context all contribute to the metacommunication that informs interpretation of the verbal statement. Stress is generated within the individual and the corresponding system when a message has at least two levels of conflicting communication such that the person receiving the message is unable to obey the one level without disobeying another level of the directive (e.g., a double-bind message or paradoxical injunction). In a seminal text for communication theory, Watzlawick, Beavin, and Jackson (1967) emphasize the importance of examining semantics, syntax, and pragmatics within interpersonal communication patterns.

MRI Interactional Family Therapy

The Mental Research Institute (MRI) in Palo Alto, California, founded in 1959 by Don Jackson, whose team included Virginia Satir, Jules Riskin, Gregory Bateson, Jay Haley, John Weakland, and, later, Paul Watzlawick, trained many influential practitioners and researchers. MRI family therapy is brief and directed by the therapist, with the responsibility for change located in the therapist rather than the client. Treatment is focused on the specified problem that the family brings to the therapist, and the therapist seeks to change problematic family rules and paradoxical patterns of communication. People are not viewed as resistant to change; rather, they are “stuck” in their current pattern of behavior that continues to lead to poor outcomes. The time-limited approach conceptualizes difficulties as the inappropriate solutions families use to solve “mishandled” difficulties in daily life. Therapists do not require all members of the family to be present in session, but therapists work as a team to assist with facilitating quick change in family interaction processes. (Goldenberg, Stanton, & Goldenberg, 2017). Key concepts developed at MRI including first-order and second-order change and the therapeutic double bind led to the development of novel strategies. First-order changes are exemplified through surface-level changes that do not impact the structure of the system. Second-order change involves foundational alterations of the system’s organization, pattern of interaction, and function. Second-order change is necessary in familial and organizational environments to produce lasting change. The therapeutic double bind is a technique that utilizes paradox to assist the clients in recognizing their ability to change the situation (e.g., prescribing the symptom or relabeling) (Goldenberg et al., 2017).

Strategic Family Therapy

Strategic Family Therapy is a brief therapy model, co-created by Jay Haley and Cloé Madanes (Haley, 1976). Haley was influenced by experience on the Bateson Project, structural family therapy, and the work of Milton Erickson, a psychiatrist who utilized hypnosis to assist in creating change within patients and who emphasized the importance of paradoxical directives (e.g., instructing a patient to maintain a symptom). The strategic family therapist is responsible for using directives to create change within the presenting problem, identified by the family. The therapist seeks to create unique solutions for each family, with a focus on solving specific presenting problems rather than uncovering deeper processes. Interventions shift the organization of the family so the original presenting problem no longer has the same purpose or effect that it once held. Paradoxical interventions are utilized to alleviate fear of change, parallel with encouraging family members to pursue changing dysfunctional patterns by highlighting their ability to be in control of the symptom.

The Milan Systemic Model (Systemic Family Therapy)

Dr. Mara Selvini-Palazzoli and eight additional psychiatrists founded the Milan Systemic Model, which was closely linked with the early MRI group. Influential concepts from the Milan Systemic group include the use of structured engagement, counter-paradox (similar to paradoxical intervention), positive connotations, rituals, and circular questioning (Boscolo, Cecchin Hoffman, & Penn, 1987). The use of structured engagement with the client facilitates connection, conceptualization, and consultation with team members, in order to assist the clinician from being pulled into family patterns. Positive connotations are utilized as a way of reframing the view of the person who is acting out, and highlighting the positive intention behind the behavior while simultaneously not condoning the behavior. Rituals are prescribed activities that facilitate further observance and connection between family members as they gain additional awareness of differences and roles within the family. Circular questioning is utilized as the therapist explores the opinions and experiences of each family member, seeking their insights while exposing other family members to alternative experiences of the interaction.

Solution-Focused Brief Therapy

Building on his experience with the MRI group, Bateson’s theory of communication, and the work of Milton Erickson, Steve de Shazer and his wife, Insoo Kim Berg, co-founded the Brief Family Therapy Center in Milwaukee, Wisconsin, and along with colleagues, co-created Solution-Focused Brief Therapy (SFBT). SFBT quickly shifts the focus of therapy away from problems, toward solutions (De Jong & Berg, 2013). SFBT is a strengths-based, brief therapy model that honors the family members as the experts in their lives; the therapist seeks to utilize language to assist the family in recognizing personal solutions. The tenets of SFBT are grounded in the importance and influence of language, construction of solutions within the client’s context, and the reciprocal relational influence among family members. De Shazer differed from the other strategic approaches when he positioned the family as the expert who holds the source of wisdom for what action to implement to resolve the problem, and viewed the therapist as no longer solely responsible for creating change. Beginning with a question to each member of the family, “How can I be helpful to you?,” the therapist focuses on what will be different in the family’s life when the problem is solved. The root of the problem is not addressed, only the solution. The SFBT provides a framework for the clinicians’ use of language within the session, and the exploration of the family members’ desires.

Family Systems Within Larger Systems

Family systems therapies recognize the influence of larger systems upon families and the therapeutic enterprise. Urie Bronfenbrenner (2005) provided the dominant theoretical frame for viewing the multiple layers of systems within which families function. He frames the integrated nature of human relations and human development across the life span and emphasizes the reciprocity of interacting social systems on individuals, families, communities, organizations, culture, and world events. His biopsychosocial ecology theory views human development as “nested” within four settings, comparable to a set of nested Russian dolls: the microsystem, mesosystem, exosystem, and macrosystem. The microsystem is the intrapersonal and interpersonal influences evidenced in close relationships such as individual characteristics, family relationships, close friends, and others who have regular and intimate interaction with the developing person over a period of time. The mesosystem contains the settings in which the developing person interacts during a particular developmental phase, such as elementary school or work environment. The exosystem includes the systemic elements in the external organizations or corresponding relationships that influence the individual, such as, “the parents’ workplace, family social networks, and the neighborhood-community contexts” (Bronfenbrenner, 1993, p. 40). The macrosystem is seen within the larger community, culture, and societal and government influences. Each of these influences are embedded within a chronosystem, a certain time period, with specific cultural, societal, and world events that influence the corresponding reciprocity between nested levels and the developing human and family relationships (Bronfenbrenner, 2005). Bronfenbrenner’s work on the dynamic intersections of influence within reciprocating systems highlights the value of engagement in larger systems. Family therapists are educated and positioned to influence and assist with facilitating change across a variety of social structures including individuals, families, educational systems, organizations, society, and culture.

Family systems therapy can be applied to all of the layers of the Bronfenbrenner model. For example, schools are a setting in which family therapists may engage productively. Schools have a unique influence on a child’s development, set within a specific context influenced by socioeconomic status, availability of community resources, level of physical safety, family dynamics, and cultural influences. Reciprocal influence between the family of origin and the school system is evidenced by the patterns at home influencing the pattern of behavior at school. The intersections of values, interpersonal dynamics, level of ability, and socioeconomic status have a pervasive influence on the developing child, academic performance, and career choice, which in turn influences the development of the community at large. Family systems therapists can work within schools and the larger community in a variety of areas including advocacy, public policy, community resilience training, and family therapy.

Similarly, organizations are another setting in which family systems therapy can be applied, using systemic concepts such as boundaries, hierarchy, homeostasis, interdependence, chaos, and reverberation in interpersonal and systemic contexts that influence employees, family members, productivity, and society at large (Fuqua & Newman, 2002; Stanton & Welsh, 2011). Professionals who provide family systems interventions are able to work as embedded employees or in a consultant role within a wide range of organizations, including behavioral healthcare, medical facilities, family businesses, educational settings, and corporations.

Systemic epistemology and intervention provide a philosophical and therapeutic frame for holistic conceptualization and effective intervention within communities and the larger culture. Culture in family systems is understood as the macrosystem with a powerful level of influence on individual, familial, and organizational development and function. Family therapists are trained to assess, conceptualize, and work within cultural patterns to promote healthy change as a valuable and necessary aspect of life. Family systems interventions encourage acceptance of complexity (the movement away from homeostasis toward disequilibrium laden with the potential for change), and reciprocity between systemic factors (Stanton & Welsh, 2012).

Summary

Family therapy introduced a novel way of examining individual behavior by adopting a systems approach to focusing on the transactions among family members. Although the models emerged with a focus on child-rearing families, their principles apply across the life span as family structures change with the development of individuals and shifts in interpersonal relationships. The models of family therapy vary substantially yet share a focus on the interpersonal communications accomplished through action as well as language.

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