Family and Psychiatric Illness: Family Therapy

Judith Lask, Kings College London, London, UK; and United Kingdom Council for Psychotherapy, London, UK
Ó 2015 Elsevier Ltd. All rights reserved.
This article is a revision of the previous edition article by J. Leff, volume 8, pp. 5298–5303, Ó 2001, Elsevier Ltd.

Abstract

The practice of Family Therapy and its theoretical underpinnings have been evolving for more than 60 years. Family Therapy,
Family Interventions, and Systemic Family Practice are in many parts of the world accepted as key components of mental
health services. There is increasing evidence to support the value of systemic approaches and an increasing commitment from
practitioners to develop and work from a sound evidence base. This article gives a brief overview of Family Therapy and other
family interventions, and the theories informing their practice. Evidence for efficacy is examined and current applications
are discussed.

The practice of Family Therapy and its theoretical underpin- to include parents in treatment. By the 1980s the profession of
nings have been evolving for more than 60 years and Family Family Therapist was developing in a number of countries and
Therapy, Family Interventions, and Systemic Family Practice appointments of Family Therapists were being made in Child
are in many parts of the world accepted as key components of and Adolescent Mental Health Services. Family Therapy has
mental health services. There is increasing evidence to support now become established as one of the main evidence based
the value of systemic approaches and an increasing commit- treatments available to children, young people, and their
ment from practitioners to develop and work from a sound families. In adult mental health the developments have been
evidence base (Eisler and Lask, 2009; Carr, 2014a,b). This more uneven. This is understandable when the role of the
article provides a brief overview of Family Therapy and other family is less clear; however, the value of Family Therapy and
family interventions, and the theories informing their practice. Family Interventions has proved important in supporting
The evidence for their efficacy is examined and current appli- families and engaging them in helping a family member with
cations are discussed. mental health problems. Systemic approaches are also helpful
The beginnings of Family Therapy can be found in the fields in working with complex professional systems and other care
of both adult and child mental health. In the 1940s and 1950s groups such as hostels and day centers.
there was an interest in the way in which communication
within families might give rise to schizophrenia in a family
member (Singer and Wynne, 1966). Although this idea has What Is Family Therapy?
been shown to be erroneous, the focus on patterns of
communication, including ‘the double bind theory,’ has been This is a more complicated question than it seems. Although
influential and added to our understanding of the way in which the idea of the system being important is foundational, family
families can have profound effects on the mental health of therapy is broad based and contains many approaches to
individuals. Unfortunately the idea that there is a direct (often thinking about and working with families and other systems.
one way) relationship between family dysfunction and indi- Some approaches focus on working with patterns of behavior,
vidual problems persisted for some time. However over the last others with beliefs or emotional attachments, and yet others
25 years there has been a growing awareness that this expla- with trans-generational influences. Some psychiatric problems
nation is a serious over-simplification of a very complex are more likely to respond to one approach rather than
process. In current practice, families are seen as resources and another but there is also an emphasis on adapting the
working partners rather than the main cause of problems. approach to best fit a particular family. Value is placed on
Genes, personality, life experience, social and economic envi- engagement and collaborative working, both of which are
ronments, and health together with families and other rela- increasingly accepted as key components of successful and
tionships are joint contributors to both psychiatric illness and ethical psychological treatments. Family Therapists also have
well being. a broad definition of the family and will pragmatically work
Work in the areas of child development, attachment, and with the most important people around a referred child or
adult mental health has highlighted the importance of family adult. This may involve seeing the whole family together, parts
and other relationships in the development of good mental of the family (sub-systems), or the family without the referred
health (Rutter, 2006). Conversely relationship dysfunction can patient. Decisions are made on the basis of who is available
give rise, and contribute, to mental health problems such as and the agreed focus of the work. Sometimes interventions
depression, anxiety, attachment disorders, and phobias. In may be made with other systems such as professional systems
Child and Adolescent Mental Health there is unsurprisingly, or friendship networks or, in Multi-Family Therapy, a number
a greater awareness of the importance of families, carers, and of families may be seen together (Asen and Scholz, 2010).
other systems around the child and the need to include them in Fundamental to Systemic Family Therapy is the idea that we
any treatment plan. In the 1960s, Bowlby, among others, began are all affected by relationships with others and if the systems

International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 8 http://dx.doi.org/10.1016/B978-0-08-097086-8.27027-X 745
746 Family and Psychiatric Illness: Family Therapy

around us work well and support recovery this will make one generation to another may also be a factor in maintaining
a positive difference to outcome, The next section will contain these unhelpful interactions.
a broad overview of the foundational ideas of current practice Another fundamental idea is that what happens to one part
followed by a discussion of the evidence base of some of these of the system inevitably affects other parts of the system. In this
approaches and an outline about how they may be used way we are all impacted by what happens to those with whom
in practice. we are in relationship and what we do affects them. Family
therapy in child psychiatry began to develop because of
observations that children in individual therapy were unable to
Theoretical Overview move on because of the way their family behaved toward them.
Approaches at this time were more influenced by psychody-
Systemic Family Therapy is concerned with the functioning of namic ideas but over time these ideas have been used to a lesser
families and other systems and different approaches focus on degree in Family Therapy practice.
particular aspects of systems. Early approaches were influ- The 1960s saw the development of structural Family
enced by cybernetics and the idea of self-regulating systems. Therapy which focuses on the importance of clear organiza-
The focus was on mechanisms that moderated the dual tional structures, roles, and responsibilities in families. This
aspects of change and stability. In this way problems were approach suggested that problems were most likely to develop
often seen as attempts to keep a system stable. For example, when the structure of the family was unclear, relationships were
a young person with eating disorder may keep a family either too distant or too enmeshed, or children were paren-
together by requiring family members to focus on an ill child tified. Sometimes individuals become ‘triangulated’ or caught
because of fear that the family may break apart once child- up in the problems between others (perhaps a child caught up
rearing is accomplished. In this sense the problem is seen to in parental conflict). As with family life cycle theory, criticisms
perform a function for the system. There was also a focus on were made that it presented a very narrow, white middle class
patterns of communication – for example, patterns which view of family life. However the ideas are still very useful as
lead to escalation but do not resolve the problem (Bateson, long as account is taken of family differences including class
1972). Elements of both of these approaches are to be and culture. Interventions are often carried out within family
found in current systemic therapies but no longer is each seen sessions with the aim of helping families to relate in more
as the ‘answer’ but one part of a complex jigsaw of cause, positive ways. For example where an adult daughter is caught
influence, and effect. up in the conflictual relationship between her parents, the
Provision of a context that allows for both change and therapist may encourage the parents to have a discussion while
stability is important as families help members to adapt to the therapist ensures that the daughter does not intervene. This
developmental and contextual changes. Family Life Cycle allows them all to have the experience of communicating in
Theory (Carter and McGoldrick, 2004) influences all major a different way.
approaches in Family Therapy. It is a way of encapsulating the The same period saw the development of Strategic Family
interaction between family, wider contexts, and the develop- Therapy that focuses on stuck behavior patterns, natural resis-
mental needs of individuals. It outlines the way in which all tance to change, and the need to devise creative solutions to
families have to adapt and change over time. Unexpected encourage people to make those changes. It assumes that
events such as untimely death, forced migration, or unem- insight is not always possible and does not inevitably lead to
ployment will impose extra demands. When the demands for change. In this approach between sessions family tasks are
change are too great or there are conflicting demands (such as often set. The focus is change in repetitive behavior patterns.
need for adolescent independence when there are serious For example a therapist may ask a couple to ‘put off’ their daily
external threats) individuals may develop problems such as arguments until after the evening meal and then to sit down
depression, anxiety, or substance abuse. Flexibility and adapt- and argue for 15 min. The idea is that if an argument is taken
ability are important aspects of individual resilience and they out of its usual context it may have a different flavor, some of
are equally important in families. Thus, those who are able to the high emotion will be decreased and the instruction to do so
adapt their roles and responsibilities, beliefs, and behavior may lead to some reflection and even rebellion! As time pro-
to fit new circumstances will be more resilient to adversity gressed concern grew about the possibility of this approach
(Rutter, 1999). being manipulative but the ideas can be used in an open and
The idea of circularity is another key idea in systemic work. transparent way with due care and attention to ethical practice.
This refers to the way in which patterns of behavior can become Another approach that focuses on behavior change is
repetitive circular processes. The following example is influ- Family Interventions in Psychosis (Lam, 1991). This has been
enced by attachment ideas which have been an important shown to be an effective approach in reducing relapse rate for
recent influence on Family Therapy. An anxious husband seeks those who have developed a psychotic illness and focuses on
reassurance from his wife who is preoccupied with work, which psycho-education and reduction of high emotional intensity,
leads his wife to become irritated and to resist his demands especially negative and critical comments. This is a good
which in turn makes him more anxious and more ‘needy’ example of the therapist taking a collaborative position and
which, in turn, is more intolerable for his wife who has a need working with the family as a team in order to help a family
to feel independent. This may be an oft-repeated pattern that member with serious mental health difficulties. In the early
can be described as ‘stuck’ and does not lead to any resolution days of Family Therapy there tended to be a focus on the family
or change. Meanwhile the husband’s anxiety symptoms may as the cause for schizophrenia and other psychoses. Patients
lead to a psychiatric referral. Family patterns passed down from were seen as being caught in a ‘double bind.’ The double bind
 Family and Psychiatric Illness: Family Therapy 747

was defined carefully as a contradiction within the verbal couples, and families look at alternative narratives which better
content of a message, or between the words used and the fit their lives and help them to move forward. The process of
feelings expressed. In addition, the recipient of the message is understanding how narratives are formed challenges their truth
not allowed to comment on the contradiction or leave the and opens them up to examination. The therapist becomes
relationship (the doubling of the bind) (Singer and Wynne, a witness to new developments in the patient’s life and cele-
1966). At this point little account was taken of the effect on brates and highlights positive changes, emphasizing the
families of living with a member with serious psychiatric patient’s personal agency in making the changes. An interven-
illness. Studies into the consequences of the discharge of tion from this approach, widely used with people with
chronic psychiatric patients into the community found that psychiatric illness, is ‘externalization.’ The illness is separated
relapse rates were higher when the discharge was to close from the person by speaking of it as an external entity. Ques-
relatives (Leff and Vaughn, 1985). This led to the study of high tions will be asked about how the ‘anorexia’ affects everyone’s
emotional intensity as an important factor in relapse (Butzlaff lives and there follows an exploration of the ways in which it
and Hooley, 1998). National organizations were set up by has been possible to control ‘anorexia.’ The aim is to identify
relatives of patients – such as the National Schizophrenia ‘unique outcomes’ which serve to question the assumption that
Fellowship in the UK and the National Alliance for the the person is totally inhabited by the illness and is helpless.
Mentally Ill in the US. This further raised the profile of families These unique outcomes are developed in order to generate
who were often judged negatively or marginalized by mental useful tools to help reduce the power of ‘anorexia.’ A similar
health services. Research in the 1970s and 1980s showed that approach, used on its own or as part of an integrative approach,
a program of psycho-education help, with reducing negative is Brief Solution Focused Therapy (De Shazer, 1985) which
comments and increasing problem solving, reduced relapse identifies and helps reinforce a person’s own preferred ways of
from 50% to 20%. fighting symptoms. For example, someone might state that if
During the 1970s and 1980s some important developments their partner smiles at them in the morning it ‘gets the day off to
took place in Milan in Italy where the approach called Milan a better start.’ The partner may be asked to smile even though
Systemic Therapy was developed (Boscolo, 1987). This they do not feel like it. Embedded within many of these
approach highlighted the importance of beliefs as determinates approaches is the idea that a small change can have a beneficial
of behavior, relationships, and emotions. The context for the ripple effect throughout the family.
development of these ideas was closure of large psychiatric These ‘postmodern’ approaches have led to therapy teams
hospitals and the need to treat people as out patients and being used in different ways. They can be used in narrative
involve their families. This approach developed questioning therapy as groups of witnesses commenting on new develop-
techniques (Fleurides et al., 1986) and encouraged the thera- ments in someone’s life or perhaps as reflecting team who
pist to retain curiosity as they explored the connections come into the therapy room and share different perspectives on
between problems and relationships. Techniques included the issues being discussed.
Socratic questioning similar to that utilized in cognitive Open dialogue approaches in the treatment of serious
behavior therapy but also included ‘circular questions’ which mental illness (Seikkula, 2006) is a recent development. This
explored the connections between relationships, beliefs, and approach involves family members and members of the
behavior. These questions were used to gather information professional network who meet together to talk. The assump-
about how the system worked, explore hypotheses, and also act tion is that solutions will emerge out of the unstructured
as an intervention to help family members become observers of conversations. This has proved to be helpful at times of crisis
themselves and explore new ways of seeing things. This and enables everyone including the patient to be heard and for
approach also gave rise to developments in team working and new ways forward to be decided.
the use of a one-way screen through which team members More recently Family Therapy has developed a greater
observed the therapy session and had mid-way discussions interest in emotions and the way they are connected to beliefs,
with the therapist in order to share ideas and present alternative relationships, and behavior. Emotionally Focused Couple
viewpoints. The next developments often called ‘Post Milan’ Therapy is an example of such an approach. It combines
took a postmodern position and rejected simplistic cause and attachment ideas, communication coaching, and trans-gener-
effect. More account was taken of the value of open dialogue in ational ideas with systems theory (Johnson, 2004). Narrative
therapy, the exploration of meanings, and the evolution of new Attachment Therapy developed by Dallos and Vetere has
ideas. Therefore, for example, a depressed family member may a similar focus.
come to be seen as bravely struggling against depression rather
than as a failure. This will alter the way other family members
relate and behave. This ‘reframing’ is a key intervention in Values and Ethics in Current Practice
a number of approaches.
Narrative approaches to therapy developed from the 1980s Systemic approaches emphasize the importance of context in
and focused on the way that all of us develop ‘narratives’ to determining the way we live our lives and the practice of Family
make sense of the world and emphasizes the way in which Therapy has of course also been influenced by the societal and
those narratives shape the way we live our lives (Morgan, professional contexts. The focus currently is on creating a strong
2000). There is a particular focus on the way in which wider therapeutic alliance (Escudero et al., 2008), working collabo-
systems such as community, culture, professional systems, ratively with family members and other clients, and respecting
education systems, media, and so on contribute to, and shape individual aspirations. There is a strong focus on respect for,
those narratives. The role of the therapist is to help individuals, and taking account of difference in relation to gender, culture,
748 Family and Psychiatric Illness: Family Therapy

religion, ability, and other dimensions of difference (Flaskas indicates that Cognitive Behavior Therapy (CBT) is a preferred
et al., 2005). There is also a strong emphasis on working first line approach this does not work, or does not work suffi-
from a strength and resilience perspective and appreciating the ciently for everyone. Narrative reviews of controlled trials of
capacity of family members to overcome most difficulties as systemic interventions for depression support the effectiveness
they go through life. There is more humility about the fact that of outpatient and inpatient systemic couples therapy, Family
no approach works effectively with everyone. Systemic Therapy based on the McMaster Model, Emotionally Focused
Psychotherapists work hard at understanding their own issues Couples Therapy, Behavioral Couple Therapy, Cognitive
and experience and the way in which these affect their work. Marital Therapy, and Conjoint Interpersonal Therapy (Barbato
Experience can be a resource but at times may constrain the and D’Avanzo, 2008). All of these approaches to Couples
work and, for example, lead to an avoidance of certain ques- Therapy require fewer than 20 sessions and focus on relation-
tions or a fear of upsetting a particular family member. Many ship enhancement, mood management, stress reduction, and
systemic psychotherapists do have their own therapy but work damage limitation for other family members.
on the interface between personal and professional is usually Studies by Leff et al. (2000) and Lemmens et al. (2009)
done in groups as part of their course and not termed ‘therapy.’ show that Systemic Couple Therapy is more effective than
When a number of individuals have to be taken into medication at 2-year follow up. Lemmens et al. utilized a mix
account, the ethics of practice become more complex especially of multi-family groups, couple sessions, and family sessions
when there are power differentials and conflicting needs. There and found that the outcomes were much better than medica-
is a clear remit to prioritize those who are most vulnerable, and tion alone.
the safeguarding of children is a priority. Most people have Early on in the history of Family Therapy there was an
a commitment to integrative working although some will focus interest in the origins of psychosis and the possible ways family
on one particular approach. There is a clear requirement for interactions could exacerbate problems. While it is clear that
Family Therapists to work within the boundary of their own there is no straightforward causal link between psychosis and
training and skill and to consider other approaches and treat- family interaction, work on family interventions in psychosis
ments which would be helpful as an alternative or adjunct to has shown the value of an approach which combines psycho
their work. education with lowering the levels of expressed emotion.
Pfammatter et al. (2006) carried out a review of three meta-
analyses of psycho-educational Family Therapy together with
What Is the Evidence for Systemically Based a new meta-analysis of the 30 best trials. They found that
Psychological Therapies? multimodal programs including both psycho-educational
Family Therapy and medication led to lower relapse rates and
Especially where psychological therapies are delivered in public less hospitalization.
sector services it is important to gain as much information as Family based therapies have been shown to be effective
possible about their efficacy and more specifically which with agoraphobia and panic disorder, and with OCD.
aspects of therapy are most useful and in what circumstances. Systemic interventions create a context in which families can
Health economics assessments of approaches are now support recovery and a forum within which family interaction
a common requirement. In a series of US studies it was shown patterns maintaining symptoms can be addressed (Renshaw
that the medical cost offset associated with Family and Couple et al., 2005).
Therapy at least covered the cost of the therapy and sometimes Behavioral Couples Therapy is an established approach in
exceeded it (Crane and Christenson, 2012). The links between working with people with alcohol problems. Typically, treat-
childhood psychiatric disorder and adult disorder are well ment includes a sobriety contract, help with problem solving,
documented so that although this section is divided into adult communication training, and relationship enhancement work
and child, it is clear that this is more a reflection of the orga- (O’Farrell and Clements, 2012).
nization of services than the reality of life. Research into work As the focus of this is psychiatric illness it is worth
with families is particularly complex because the focus is rarely mentioning the role of Couple Therapy, Family Therapy, and
exclusively on the referred patient. Measures into family func- mediation in the process of separation and divorce. The rela-
tioning are not entirely satisfactory and can be cumbersome. tionship stress associated with the process of divorce and
The development of the SCORE measure of family functioning separation and the risks for the mental health of children and
provides a new, easy to use, clinically based measure which will future adults makes it important to consider the value of
be of assistance in much needed research into Systemic Family systemic approaches which not only work with the couple but
Therapy especially in Child and Adolescent Mental Health also with the children. They will keep the needs of the children
(Stratton et al., 2014). paramount and help parents to collaborate in creating the best
outcomes despite their own strong emotions.
It is not surprising that family approaches have a significant
Depression and Anxiety
part to play in the treatment of child and adolescent psychiatric
The incidence of depression and anxiety is high with almost problems. Although the differences in many studies are small
a fifth of adults in the UK reporting signs of depression and the evidence for family interventions is growing, with a
anxiety. The condition is highly distressing for the person number of recent well designed and large scale studies. A
suffering from depression and also for other family members, number of recent reviews provide a general overview of the
including any children, In the UK the incidence of anxiety and evidence for the field as a whole (Carr, 2014a,b) as well as
depression in children is on the rise. Although current research for problem specific areas such as alcohol and drug abuse
 Family and Psychiatric Illness: Family Therapy 749

(Hogue and Liddle, 2009), conduct disorder and delinquency, refeeding and getting to a safe weight. It will involve ‘exter-
eating disorders, anxiety disorders, and mood disorders nalizing’ and helping parents to feel more skilled with their
(Cosgrove and Chang, 2013). young person. Work with psychosis will usually involve some
With most problems the differences between Family psycho-education and emotionally focused couple work for
Therapy and other active treatments are relatively small but depression will focus on managing strong emotions and
with some there is consistent evidence of Family Therapy meeting each other’s attachment needs.
leading to better outcomes. This is particularly the case for The number of sessions is sometimes prescribed (often
behavior problems, youth offending (Sydow et al., 2013), between 6 and 12) but some pieces of work go on for longer
and substance misuse (Tanner-Smith et al., 2013) where the and there may be variable lengths of time between sessions.
evidence from around 30 RCTs provides clear support for the Engagement of all family members is always a crucial aspect of
use of Family Therapy both in terms of outcome and the work and very often the completion of a genogram will
engagement in other parts of the therapeutic program help to track information about the family and identify
(Stanton, 2004). patterns over time. Family Therapy may be a treatment on its
Similarly, there is now compelling evidence for Family own or an adjunct to other treatments and can be useful in
Therapy in the treatment of eating disorders (Couturier et al., engaging clients and encouraging compliance with other
2013) with recent larger studies confirming its superiority in approaches. It is a method that over many years has given to
the treatment of anorexia nervosa in comparison with an client feedback and collaborative working to identify what each
adolescent focused individual therapy as well as its role in the family and family member finds helpful. There are a range of
treatment of bulimia nervosa. nonverbal interventions such as genograms, drawing, and
For other problems such as anxiety disorders (including timelines. When small children are in sessions play and art
OCD), depression, or bipolar disorder there is evidence that materials are used to ensure the child is involved in a session
family interventions are effective but the comparison with and able to communicate in a way that is age appropriate.
other treatments is less straightforward. Some studies have Experiential techniques such as family sculpting or role-play
shown that where the parents themselves are anxious the may be used. Between session tasks, diaries and research tasks
family intervention may be more effective and there are data are also commonly utilized.
suggesting that even when there is no difference between All psychiatric illness affects others and can be adversely and
changes in anxiety symptoms, the family intervention leads to positively affected by those around the ill person. Family
greater changes in general functioning both at the individual Therapy has a key role in helping recovery and lessening the
and family levels (Khanna and Kendall, 2009). Two groups risk of relapse, as also in limiting potential damage to other
have evaluated Systemic Family Therapy for depression in members of the family.
children and adolescents and shown them to be effective in
comparison with control (Diamond et al., 2002) and compa- See also: Anxiety and Anxiety Disorders; Behavioral Problems,
rable to psychodynamic psychotherapy (Trowell et al., 2007). Effects of Parenting and Family Structure on; Bowlby, John
(1907–90); Child Protection; Child and Adolescent Psychiatry,
Clinical Practice Principles of; Children and Families in Social Work; Cultural
Although there is good evidence that Family Therapy can be Views of Life Phases; Depression; Eating Disorders; Emotional
effective with a range of problems there has to be caution in Development, Effects of Parenting and Family Structure on;
translating research findings into practice. They can indicate Evidence-Based Psychiatry; Family as Institution; Obesity:
useful ways to proceed but individual family factors have to be Cultural and Biological Factors; Repartnering and Stepchildren;
taken into account and culture, gender, and age can profoundly Schizophrenia; Social and Emotional Development in the
affect work with families. As previously explained, systemic Context of the Family; Stress in Infancy and Early Childhood:
work does not always have to include the whole family and Effects on Development.
there are times when this is contraindicated. Where there are
safeguarding issues it is important to see a child or a young
person on their own. High degrees of conflict may indicate that
it is better to begin with some individual sessions and then
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