Systems of Psychotherapy:Systems of Psychotherapy:A Transtheoretical AnalysisA Transtheoretical Analysis

Chapter 11 – Systemic Therapies

The Context of The Context of Systemic TherapiesSystemic Therapies

Individuals can only be understood within their Individuals can only be understood within their social contextsocial context

Contextless is meaninglessnessContextless is meaninglessness Patient is the entire system, not the identified Patient is the entire system, not the identified

patient (IP)patient (IP) General Systems Theory & cybernetics are the General Systems Theory & cybernetics are the

intellectual inspirations for systemic therapy intellectual inspirations for systemic therapy Systems = parts of an organization + Systems = parts of an organization +

relationships among those partsrelationships among those parts

HomeostasisHomeostasis

Homeostasis or balance explains how living Homeostasis or balance explains how living systems control steady statesystems control steady state

Feedback loops are the important control Feedback loops are the important control mechanismsmechanisms

Not linear cause and effect, but rather reciprocal Not linear cause and effect, but rather reciprocal effecteffect

Positive feedback loops set up runaway Positive feedback loops set up runaway situations that drive systems beyond their limitssituations that drive systems beyond their limits

Negative feedback loops decrease deviations Negative feedback loops decrease deviations from system rulesfrom system rules

Multiple Meanings of Multiple Meanings of Systemic TherapiesSystemic Therapies

1.1. Therapy modality or format Therapy modality or format

2.2. Treatment content or goalTreatment content or goal

3.3. Paradigm shiftParadigm shift

Three Systemic Therapies Three Systemic Therapies

Communication/strategic therapyCommunication/strategic therapyStructural therapyStructural therapyBowenian therapy Bowenian therapy

Communication/StrategicCommunication/StrategicTherapy Therapy

Mental Research Institute (MRI) & Double Mental Research Institute (MRI) & Double Bind Communications ProjectBind Communications Project

Key figures: Jay Haley, John Weakland, Key figures: Jay Haley, John Weakland, Donald Jackon, Virginia SatirDonald Jackon, Virginia Satir

Communication is key to understanding Communication is key to understanding behaviorbehavior

Assume that all behavior is communicationAssume that all behavior is communicationClassic example: double bindClassic example: double bind Interventions change communicationInterventions change communication

Theory of PsychopathologyTheory of PsychopathologyPsychopathology is a function of unclear Psychopathology is a function of unclear

or hostile communicationor hostile communicationPathology is family’s homeostatic Pathology is family’s homeostatic

mechanism to maintain system balance ofmechanism to maintain system balance ofPsychopathology occurs when rules of Psychopathology occurs when rules of

relating become ambiguous relating become ambiguous Unclear communication patterns make Unclear communication patterns make

rules ambiguous rules ambiguous

5 Axioms of Communication5 Axioms of Communication1.1. It is impossible not to communicate; silence is It is impossible not to communicate; silence is

ambiguous communicationambiguous communication2.2. Communication implies commitment and Communication implies commitment and

defines relationships; both report and defines relationships; both report and command elements command elements

3.3. Relationships are contingent on how a Relationships are contingent on how a communication is punctuated or endedcommunication is punctuated or ended

4.4. Communication is both verbal and nonverbal Communication is both verbal and nonverbal 5.5. Communications are symmetrical (either side Communications are symmetrical (either side

can lead the communication) or can lead the communication) or complementary (one side leads)complementary (one side leads)

Theory of Therapeutic Theory of Therapeutic ProcessesProcesses

Help individuals and systems to Help individuals and systems to communicate clearly & constructively communicate clearly & constructively

Changing communication changes Changing communication changes relationships and power dynamics relationships and power dynamics

Processes of ChangeProcesses of Change

Consciousness raising: aware of rules for Consciousness raising: aware of rules for communicating and relatingcommunicating and relating

Choosing: straight directives and Choosing: straight directives and paradoxical techniquesparadoxical techniques

Catharsis: Satir’s emphasis on feelings Catharsis: Satir’s emphasis on feelings Counterconditioning: Haley’s emphasis Counterconditioning: Haley’s emphasis

on power and ordeal therapy on power and ordeal therapy

Therapeutic RelationshipTherapeutic Relationship

Develop an atmosphere conducive to Develop an atmosphere conducive to congruent communicationcongruent communication

Empathy and positive regard are Empathy and positive regard are importantimportant

Therapist is in charge and in controlTherapist is in charge and in control Therapist uses direct and indirect Therapist uses direct and indirect

techniques to control relationship techniques to control relationship

Effectiveness of Effectiveness of Communication/StrategicCommunication/Strategic

Not a lot of controlled outcome studiesNot a lot of controlled outcome studiesEffective in tx of substance abusersEffective in tx of substance abusersUncertain effectiveness in schizophrenia, Uncertain effectiveness in schizophrenia,

anxiety, & psychosomatic disordersanxiety, & psychosomatic disordersParadoxicals are as effective as Paradoxicals are as effective as

straight/direct interventions straight/direct interventions

Structural TherapyStructural Therapy

Developed by Salvador Minuchin (1922 - )Developed by Salvador Minuchin (1922 - )Created to treat delinquents as systemic Created to treat delinquents as systemic

issue rather then individual problem issue rather then individual problem Initial focus on delinquency and anorexia Initial focus on delinquency and anorexia

nervosa nervosa Influential and pragmatic approachInfluential and pragmatic approach

Structural Theory of Structural Theory of PsychopathologyPsychopathology

Structural theory is more concerned with Structural theory is more concerned with what maintains psychopathology than with what maintains psychopathology than with its causes its causes

Historical causes cannot be empirically Historical causes cannot be empirically determined and cannot be changed determined and cannot be changed

Dysfunctional dynamics of the family Dysfunctional dynamics of the family system maintain psychopathology system maintain psychopathology

BoundariesBoundariesAn organized family has clearly marked An organized family has clearly marked

boundariesboundariesDisengaged families have rigid boundaries Disengaged families have rigid boundaries Enmeshed families have diffuse boundaries Enmeshed families have diffuse boundaries Dysfunctional families respond to demands Dysfunctional families respond to demands

for change in pathological waysfor change in pathological ways

Structural Theory of Structural Theory of Therapeutic ProcessesTherapeutic Processes

Goal: restructure families to free members Goal: restructure families to free members to grow and relate to grow and relate

Changing family structure involves Changing family structure involves changing rules for relating and boundaries changing rules for relating and boundaries

Consciousness Raising: education, Consciousness Raising: education, reframing reframing

Choosing or social liberation: Minuchin as Choosing or social liberation: Minuchin as freedom fighter freedom fighter

Therapeutic RelationshipTherapeutic Relationship

Therapist joins each member or sub-Therapist joins each member or sub-system of family system of family

Initial relationship involves empathy, Initial relationship involves empathy, warmth, and caringwarmth, and caring

Once relationship established, therapist Once relationship established, therapist becomes authoritative leaderbecomes authoritative leader

Therapist challenges, blocks, & disrupts Therapist challenges, blocks, & disrupts homeostasis homeostasis

Effectiveness of Effectiveness of Structural TherapyStructural Therapy

Reliance on clinical case surveysReliance on clinical case surveysFew controlled studiesFew controlled studiesFound superior to no tx and probably Found superior to no tx and probably

superior to individual tx for substance superior to individual tx for substance abuse, psychosomatic disorder, and abuse, psychosomatic disorder, and conduct disorderconduct disorder

Untested in tx of other disorders Untested in tx of other disorders

Bowen Family Bowen Family Systems TherapySystems Therapy

Developed by Murray Bowen (1913 – Developed by Murray Bowen (1913 – 1990)1990)

Initially applied to schizophrenic families at Initially applied to schizophrenic families at NIMH NIMH

Dramatically applied to his own familyDramatically applied to his own familyA cerebral and deliberate approach A cerebral and deliberate approach

Bowen’s Theory of Bowen’s Theory of PsychopathologyPsychopathology

Differentiation of self is ability to be Differentiation of self is ability to be objective & controlled about emotional objective & controlled about emotional issuesissues

Emotional illness arises when individuals Emotional illness arises when individuals are unable to differentiate from their families are unable to differentiate from their families of origin (fusion)of origin (fusion)

Fusion results in undifferentiated family ego Fusion results in undifferentiated family ego massmass

Fusion leads to triangulation Fusion leads to triangulation

Bowen’s Theory of Bowen’s Theory of Psychopathology (cont.)Psychopathology (cont.)

The child closest to parents is most likely to The child closest to parents is most likely to develop pathological symptomsdevelop pathological symptoms

Emotional cutoffs are efforts to cope with Emotional cutoffs are efforts to cope with unresolved attachments to families of origin unresolved attachments to families of origin

Family projection process Family projection process Multi-generational transmission processMulti-generational transmission process

Theory of Therapeutic ProcessesTheory of Therapeutic Processes

Goal: increase differentiation of self from Goal: increase differentiation of self from family emotional system family emotional system

Detriangulate family membersDetriangulate family membersChange produced in one triad will cause Change produced in one triad will cause

change in all family triangles change in all family triangles Consciousness raising Consciousness raising ChoosingChoosing

Therapeutic RelationshipTherapeutic RelationshipTherapists do not allow themselves to be Therapists do not allow themselves to be

triangulatedtriangulatedMaintain an objective “I” position Maintain an objective “I” position Therapists act as models of autonomous, Therapists act as models of autonomous,

responsible, and differentiated behavior responsible, and differentiated behavior Therapists rely on observation and reason Therapists rely on observation and reason

(not empathy) to understand family (not empathy) to understand family

Practicalities Practicalities

Often work with spouses or with one Often work with spouses or with one motivated patientmotivated patient

Central couple is most important Central couple is most important Strong proponent of family of origin Strong proponent of family of origin

therapy for psychotherapists therapy for psychotherapists

Effectiveness of Effectiveness of Systemic TherapiesSystemic Therapies

20+ meta-analyses indicate couples & family 20+ meta-analyses indicate couples & family therapies are effective; average ES = .65therapies are effective; average ES = .65

Positive effects remain but taper over timePositive effects remain but taper over time Martial therapy tends to show higher effects Martial therapy tends to show higher effects

than family therapy than family therapy No difference in effectiveness among different No difference in effectiveness among different

systemic therapiessystemic therapies No consistent outcome differences between No consistent outcome differences between

individual and family therapy; “for now, a tie”individual and family therapy; “for now, a tie”