Systems of Psychotherapy: A Transtheoretical Analysis

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

2. 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

3. 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

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

5. Three Systemic Therapies • Communication/strategic therapy • Structural therapy • Bowenian therapy

6. Communication/StrategicTherapy • 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

7. 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

8. 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)

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

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

25. 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”