Family Systems Therapy: How It Works & What to Expect

What Is Family Systems Therapy?

Family systems therapy is a type of family therapy that focuses on assessing the family unit from a cultural, communal, familial, and social standpoint. Its goal is to increase family functioning through adaptive development and positive change.^1,2,3,4 This kind of approach is complex because it involves many interrelated concepts and applications. It posits that behavior is both caused by and inseparable from the functioning of the family.²

What Is Family Systems Theory?

Family systems theory believes that families are complex social systems and that the behaviors within the system have the ability to influence others and change the way the system functions. The family is seen as a whole unit rather than individuals within a whole unit.

When Is Family Systems Counseling Used?

Some common family problems that warrant family systems therapy include parent-child relational issues, marital problems, sibling abuse, chronic illness within the family, parenting inconsistencies, and maladaptive emotional expression.^4,6

Other common reasons why families seek therapy include:^4,6,9,10

• Substance use disorder of a family member
• Major mental illness of a family member
• Issues with overall functioning of the family unit
• Conduct disorders/behavioral issues of a child
• Chronic illness of a family member
• External stressors such as job issues
• Communication deficits
• Depression and anxiety of members that impact family function

Core Concepts of Family Systems Therapy

The core concepts of family systems therapy emphasize how issues within the unit are both caused by and affected by the patterns within the family constellation.^1,3 The preliminary goal of this form of therapy is to shift the focus from the “identified patient” to variables and circumstances that impact the system. Family therapists often think in circles, not lines, meaning the concepts below are intertwined and can be explained in any order.^2,3

Here are some of the core concepts of the family systems therapy model:

Differentiation of the Individuals From the System

Differentiation of individual self from the system refers to your ability to identify your emotional and intellectual needs aside from your identity within the system.^2,3 This is important to take into consideration, because when you’re not able to separate yourself from others, you run the risk of codependency.

The “Triangle”

The “triangle” refers to the theory that a group of three people is the smallest interdependent system where patterns can be assessed and concepts of family systems therapy can be applied.^2,3 Any two-person relationship would be in a constant “push-pull” format described as an emotional flow and counter flow.

Dependent Children & Related Emotional Patterns

Dependent children and related emotional patterns refers to the transference of emotion after the initial triangle has been born. For example, one parent may elicit more emotional need from their partner, resulting in increased anxiety in the partner and strain on the entire family system.^2,3

Multigenerational Conceptualization, Cultural, & Societal Considerations

Multigenerational conceptualization of problems as well as societal and cultural considerations are important because they draw attention to the impact that someone’s origin and culture shapes their worldview and subsequent societal outcomes.^2,3,5

Projection Between Members

The family projection process involves parents projecting their emotions or issues onto another family member, resulting in an imbalance of emotional distribution that can cause anxiety or other conflicts. Some suggest that parental projection is related to a deficit in the parents’ ability to have a healthy differentiation of self.^2,3 It’s also theorized that the projection process is integrated with the childrens’ ability to differentiate between themselves, their parents, and their siblings.
Examples of parental projection include the insatiable need for attention or approval, blaming others for their problems, and assuming responsibility for other family members’ emotions.

Emotional Conditions & Availability

Emotional conditions and availability become significant when thinking about how an emotionally unavailable parent can result in a deficit in early attachment, which is problematic in developing a healthy differentiation of self.^2,3

Birth Order & Sibling Positions

The core concept of birth order and siblings relates to the concept of the “triangle” as it highlights that each additional member changes the dynamics. Some theories suggest that the importance of siblings and birth order is tied to an individual’s trajectory, and that it is a fallacy to suggest that children born to the same parents are raised in the same environment.⁵

Family Systems Therapy Techniques

Some common family systems therapy techniques include psychoeducation, marital counseling (as a means to improve the system), behavioral management, improving communication, fostering coping skills, future planning, vocational/job related counseling, and in some cases, medication management.^2,3,4,6 Family members might also be asked to create a genogram, which is an illustration or representation of the family tree. It should include information about each member and the relationships between them.

Additional techniques used in family systems therapy include:

• Structural family therapy: This approach focuses on the quality of the interactions between different family members to learn about the health of the family.
• Strategic family therapy: This approach focuses on how the behaviors of one or multiple family members impacts others. The goal is to help all family members get their needs met.
• Intergenerational family therapy: This approach considers the generational impact on families and family culture. It helps to identify how patterns of behavior can automatically and subconsciously be recreated, and how to modify these behaviors for better family functioning.
• Narrative therapy: This approach involves the recreating of the “story of the family” by using a strengths-based perspective to learn how to better understand the experiences within the family structure.
• Couples therapy: This approach focuses on how the parents or adults in the family can positively impact the family system by addressing relational issues within the marriage.
• Psychoeducation: This approach gives education around family systems, normalizing certain aspects of family interactions, destigmatizing patterns to help everyone feel more seen. It also walks families through how to use this education to their advantage and gives them new tools to access this education.

What Is the Goal of Family Systems Therapy?

Each family will have different reasons for coming to therapy, but common family therapy goals include exploring patterns and their relation to individual psychopathology, encouraging the family to improve functionality, increasing positive communication, restructuring maladaptive international and relational patterns, and strengthening natural resilience.⁶

In general, goals of family systems therapy usually fall into two categories: specific goals for individual family needs and general goals that apply to all families. General goals are related to familial interactions and changing maladaptive patterns, while specific goals cater to individual needs, such as specific mental health diagnoses, substance use disorders, or trauma.⁷

The Benefits of a Family Systems Approach to Therapy

There are many benefits of a family systems approach to therapy. Some of the benefits include: 

• Better functioning for families: Overall relatability and efficacy of the family improves, and the culture of the family becomes more positive.
• Stronger connections: Individual family members feel closer to one another and improve their relationship.
• More cohesive family unit: Family resilience is built and the family unit is able to provide more stability when there are issues.
• Healthier communication: The style and language used to communicate improves and leaves everyone feeling more heard, understood, and accepted.
• Cost effective for dealing with problems: The tools learned in this approach offer ongoing benefits as the skills and tools learned provide endless benefits.
• Can help prevent emotional problems in children: Children can benefit from this approach as they witness and learn healthier ways to relate to their family and are empowered to share their feelings.

Is Family Systems Counseling Effective?

The effectiveness of family systems therapy generally depends on the family’s engagement and willingness to grow. In fact, therapists across the board agree that engagement is the number one predictor of success.^1,5,16,17 Some studies show that family therapy interventions are actually the preferred treatment approach for depression, substance abuse, child and adolescent risk behaviors, suicide risk, and relational issues.¹⁰

Any family who is able to demonstrate an open mindset and work to improve systemic deficits will be able to make positive changes. That said, family therapy does not “solve” family problems. Instead, it provides tools for families to use to increase their cohesion.⁹ Factors that may hinder the effectiveness of family therapy include relapse, medication noncompliance, or certain pathologies related to personality disorders that may negatively impact treatment progress.¹¹

Risks of Family Systems Therapy

One of the risks to consider with family therapy is the competency of the therapist. Certain families may exhibit very intensive needs, so it is important to be sure that those needs match the therapist’s level of competency.⁸ Additional risks are related to certain mental health and substance-use issues.¹² Therapists working with high-risk family members who exhibit suicidal ideation or have made past suicide attempts need to ensure that their plan includes crisis response and preventative measures.^11,12

Therapists working with clients who exhibit substance use disorders will also need to explain their duty to report to child protective services if there is a concern.^1,8,11 It is encouraged that therapists in this role explain how working with child protective services can be a positive experience that fosters general health and wellness for the family.

If family members have conflicting goals that impact individual members’ well-being, it may pose additional risks in trying to create a clinically appropriate goal for the family while also catering to individual needs.¹⁸

Criticisms of Family Systems Therapy

Family systems therapy can be very intense and requires a great deal of work and compliance from all members. This can be a difficult task to achieve if the family is not ready, and studies show that families who terminate early have less successful outcomes.^11,17 When individual members demonstrate toxic or dangerous traits, it can even become ethically problematic to promote family cohesion.^1,17,18

Some argue that family therapy is practiced with little awareness of the external factors that influence behaviors such as school, workplace, or neighborhood.¹⁹ From a feminist perspective to therapy, family therapy can be seen as promoting a traditional patriarchy that supports a misogynistic conceptualization of problems. This consideration is particularly applicable when working with LGBTQ+-related family problems.¹⁹

How to Find a Family Therapist

Finding a family therapist can require a referral from a primary care physician or an individual therapist; however, families can also self-refer. Check with your insurance providers to determine whether you need a referral and whether sessions will be covered by your plan.^4,8,11 You could also search an online therapist directory, which enables you to filter therapists by state, specialty, availability, cost, experience, and language.

Key Questions to Ask

To decide whether a potential therapist is an appropriate match, families should always consider asking a few questions upfront like how much experience they have working with families.

Other key questions to consider asking your family systems therapist include:

• How much experience do you have in dealing with this type of presenting issue (e.g. substance abuse)?
• Do you have adequate cultural competency?
• Do you understand societal/cultural considerations that may be impacting stress and level of function?
• What is your level of experience using the family systems approach?
• Are there any additional considerations, assessments, or mandates that pertain to the state?

What to Expect During Family Systems Therapy Sessions

During the initial session, the therapist usually gathers information about the family system as a whole, the reason for seeking therapy, the history of certain behaviors, and cultural and socioeconomic information. Then, they work with the family to create specific and general goals like decreasing substance use and increasing adaptive family communication.⁷

Generally, family therapy is short in duration and lasts for an average of 12 sessions.^4,7,9,10

Can You Do Family Systems Counseling Sessions Online?

Family systems therapy can be done online, however effectiveness may vary depending on how the family approaches online sessions and their ability to stay engaged. Online therapy is not for everyone, so even if one member of the family is not finding online sessions to be helpful, the overall experience and outcome of therapy will be less effective.

Cost of Family Systems Therapy

Depending on the state, the typical cost of therapy can range from $75 to $200 per hour-long session.⁴ Family therapy can also be accessed through private mental health insurance; however, most insurance will not cover it unless a family member has a diagnosed mental health disorder. In these cases, the insurance company looks for an “identified client.” All intake paperwork and subsequent assessments go under that client’s name.

The identified client is usually the individual who showcases a diagnosable mental health concern like depression, conduct issues, substance abuse, or behavioral issues. This means that all clinical notes, goals, and interventions will be geared towards improving that client’s issues in the larger interest of improving family function. The treatment plan will be required to include at least one goal for the client and a separate goal for the family.^2,4,9,11

Insurance also dictates credentialing requirements on who can provide the therapy, how it can be conducted, and in some cases, what assessments can be performed. Guidelines are dependent on both the state of residence and insurance of individual members.⁴

Final Thoughts on Family Systems Therapy

Family systems therapy is a complex approach utilized to work with an intimate group of individuals who usually reside in the same dwelling. It showcases multiple approaches given the vast nature of familial issues, the multitude of influential factors, and the diagnostic considerations of individual members.