Family systems therapy is a kind of psychotherapy for multiple people who live in an intimate context, such as a family. Its core concepts include considerations of both the individual family members and system as a whole. Family systems therapy emphasizes that a system of people is dependent on its individual parts.
Family therapy has a broad spectrum of cost; however, it can be paid for privately at about $75-200 per session, or it can be accessed through insurance. Each insurance company will have different considerations and requirements for providing this form of therapy, and many will not cover it unless one family member is diagnosed with a mental disorder.
What Is Family Systems Therapy?
Family systems therapy 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 implies that behavior is both caused by and inseparable from the functioning of the family.2
Core Concepts of Family Systems Therapy
The core concepts of family systems therapy emphasize how issues within the unit are both caused 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
The core concepts of family systems therapy are:
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 your origin and culture shapes your worldview and subsequent societal outcomes.2,3,5
Projection Between Members
The family projection process is explained as the parents’ ability to project their emotions or issues onto another family member, resulting in an imbalance of emotional distribution that results in 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 offspring’s ability to differentiate between themselves, their parents, and their siblings.
Emotional Conditions & Availability
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 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 therapy
- Strategic therapy
- Systemic/milan therapy
- Narrative therapy
- Communication theory
- Reality therapy
- Relationship counseling
- Relationship education
- Psychoeducation
- Psychotherapy
Some common family problems that warrant these interventions include parent-child relational issues, marital problems, sibling abuse or other issues, illness within the family, parenting inconsistencies, and maladaptive emotional expression.4,6
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Goals: Specific & General
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 diagnoses and pathology, substance use disorders, or trauma.7
Reasons to Seek Family Systems Therapy
Common reasons to seek out family systems therapy include suicidal ideation of a family member, suicidal attempt of a family member, and parental substance abuse.
Other common reasons why families seek therapy include:
- Substance use disorder of a family member4,9,10
- Major mental illness of a family member4,9,10
- Issues with overall functioning of the family unit4,6,9,10
- Conduct disorders/behavioral issues of a child4,10
- Chronic illness of a family member4,9,10
- External stressors such as job issues4,9,10
- Communication deficits4,9,10
- Depression and anxiety of members that impact family function4,9,10
After initial safety measures are taken, the clinician will gather more information about the family system, history of behaviors, and interactional patterns placement within the family (genogram). This information allows them to assess and determine underlying causes and considerations for the family dysfunction as well as the individual diagnosis.
Parental Substance Abuse
When working with parental substance abuse it is essential to gauge safety. All therapists have an ethical duty to warn if there is ever concern of imminent harm.5,11,12 In this scenario, they would meet with the family, gather information, conduct assessments, and create a safety plan to ensure that the family is aware of their local resources in the event of a crisis.11,12
During the working phase of therapy, the therapist would work with the family to identify transgenerational patterns, previous traumas, and other influential factors in the development of the substance use disorder. Then, they would work with the family to create goals related to decreasing substance abuse, increasing function through education, and providing support for cessation of enabling patterns.6,11
Cost of Family Systems Therapy
Depending on the state, a typical cost range is $75-200 per hour-long session.4 Family therapy can also be accessed through private insurance; however, most insurance will not cover it unless a family member has a 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
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.4,8,11 You could also search through a directory like Choosing Therapy, 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 do they have.
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/expertise in the family systems approach?
- Are there any additional considerations, assessments, or mandates that pertain to the state?
What to Expect at Your First Appointment
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
Is Family Systems Therapy 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 on 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 ideations 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.
Lastly, 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, 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
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.
