8.3 Couples and family therapy

Systemic ideas

• The identified patient is the symptomatic member who is referred. Systemic therapists treat this person as the bearer of the family's symptom.

• Circular causality means each person's behaviour is both a response to the other and a trigger for the next round, so the pattern keeps itself going.

• Systemic therapists therefore ask about the sequence of events, not who started it, and they assign no blame.

• Family homeostasis, Don Jackson's term, is a family's tendency to keep its established balance and resist change.

• Because of homeostasis, improvement in one member can unsettle the family. A symptom may then surface in someone else, or the old pattern may return after relapse.

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Structural therapy (Minuchin)

Salvador Minuchin founded structural family therapy. It holds that a family's repeated transactions lay down the rules that make up its structure.

Healthy function rests on clear boundaries and an intact parental hierarchy.

Structural techniques aim to restore the parental hierarchy.

• The therapist begins by joining the family.

• Enactment brings an interaction, such as a disagreement, into the session so the therapist can work with it directly.

• Boundary making redraws boundaries in the room, for example by blocking or by moving chairs.

Strategic therapy

• Strategic family therapy (Haley, Madanes) places the difficulty in repetitive communication patterns that maintain the symptom, not in family structure.

• The therapist issues directives, which the family carry out between sessions.

• Directives are often paradoxical, such as prescribing the symptom or restraining change, so that the family's resistance is turned into change.

• A paradoxical injunction aims to alter the family's relationship to the symptom rather than simply demand its removal.

• Paradoxical injunction descends from Bateson and belongs to family therapy. It is not part of the standard cognitive behavioural therapy toolkit.

Systemic (Milan) therapy

Systemic family therapy is the Milan approach of Selvini Palazzoli, Boscolo, Cecchin and Prata. It is distinct from both structural and strategic therapy.

• Circular questioning is its core technique: the therapist asks one member to comment on the relationship between two others.

• Triadic and ranking questions are forms of circular questioning.

• Milan therapy follows three guidelines: hypothesising (testing possible systemic explanations), circularity and neutrality.

• The therapist takes a neutral stance, which later became a curious, non-expert one.

• A team watches from behind a screen or works as a reflecting team.

• Positive connotation reframes the symptom with a positive meaning, such as a protective function.

Bowen family systems therapy

• Bowen's transgenerational therapy aims at differentiation of self: staying connected to the family while keeping independent thinking.

• It often works with one motivated adult alone.

• A genogram maps relationships, illness and emotional cut-offs across generations.

• Multigenerational transmission is the passing of anxiety patterns down the generations.

• Triangulation happens when a tense two-person relationship draws in a third person, often a child, to relieve anxiety. The conflict is diverted rather than settled.

Solution-focused and psychodynamic therapy

• Solution-focused therapy (de Shazer and Berg) builds on what already works and spends little time on causes.

• Its techniques are the miracle question, scaling questions and exceptions.

• Psychodynamic family therapy puts insight and the family's history before the presenting problem, so the referral symptom gets less attention.

Expressed emotion and psychoeducational work

• Expressed emotion comprises critical comments, hostility and emotional overinvolvement.

• High expressed emotion predicts relapse in schizophrenia, but it does not mean that relatives caused the illness.

• The Camberwell Family Interview is the reference-standard measure of expressed emotion. The relative's interview is audio-recorded and expressed emotion is coded afterwards.

• Psychoeducational family work lowers expressed emotion. It explains the illness, relapse signs and treatment, and it trains communication and problem-solving.

• The National Institute for Health and Care Excellence (NICE) recommends at least ten planned sessions for people with psychosis or schizophrenia in close family contact.

Programmes for young people

Couple therapy

• The therapist screens each partner privately for coercive control and violence before conjoint work. Treating asymmetric abuse as mutual conflict is unsafe.

• Each partner's goals are explored separately as well as jointly.

• In the pursue-withdraw cycle, one partner seeks reassurance while the other retreats, and each response increases the other's fear.