Our family members are often the people with whom we have some of our most powerful relationships. They are the people to whom we are genetically or emotionally bonded, but our connections with them are not immune to conflict. Family therapy or family counseling is a form of psychotherapy that aims to reduce distress in the family system by helping members learn new ways of working together and managing challenges.
What Is Family Therapy?
In order to learn more about family therapy it is helpful to understand family systems theory,1 a framework in which many family therapy concepts are grounded. In family systems theory the family as a whole is considered to be one entity, greater than the sum of the parts of the individual family members.
Members are assessed by the family roles they take on, the family rules by which they are influenced, and their position in the family hierarchy, all within the context of the whole system. Problems are addressed by adjusting the family system rather than focusing on the problematic behavior of only one person. In other words, the therapist attempts to understand behavior within the context of the different spousal, parental, and sibling relationships.
Terms in Family Therapy
Family Systems Therapy uses several terms which are important to understand within this context. These terms are often used in other therapy contexts, but have specific meaning when applied to family therapy.
Boundaries1,2
Invisible borders within familial subsystems that delineate relationships in the family structure. Structural Family Therapy identifies three types of boundaries:
1) Diffuse or enmeshed boundaries, which allow for little differentiation between family members.
2) Rigid or disengaged boundaries, in which it is challenging for members to communicate or share emotion and family members are isolated from each other.
3) Clear boundaries, which lead to a comfortable atmosphere where the family can openly express themselves and develop deeper empathy.
Differentiation1
A family member’s ability to individuate from, while maintaining an emotional connection to, the family. A well-differentiated family member has their own life goals and sense of self, while maintaining their place in the family system.
Homeostasis1
A concept in which the family system tends to resist change and maintain its accustomed functioning and equilibrium. This notion can explain the intergenerational transmission of familial problems, behaviors, and mindsets.
Identified Patient
The identified patient (IP), sometimes also known as the target client, is the person whose symptoms brought the family to counseling. The therapist works with the family to resist scapegoating the IP for the underlying problems in the family system. In family therapy, children and adolescents are oftentimes the IP.
Triangulation1,2
When the relationship between two people becomes unstable, a third party may be involved to whom the conflict or anxiety is diverted in order to ease the tension, called triangulation. Common triangles include a child and both parents, two siblings and one parent, two spouses and an in-law, and a parent, child, and grandparent. The triangles in the family system typically interconnect in ways that maintain the family homeostasis.
What Can Family Therapy Help With?
Your reasons for initiating family therapy are unique to the circumstances of your family, but they will likely align with a few common themes.
Issues Within the Familial Relationships
Family therapy can help members address conflict and increase the quality of their emotional bonds. Parents may be concerned about their child’s defiant or aggressive behavior (often addressed in functional family therapy), social or academic problems, or symptoms of anxiety or depression. Sometimes there are problems in relationships with extended family members, particularly if they live in the home.
In today’s world it is not uncommon for grandparents, aunts and uncles, romantic partners, and other extended members to share living arrangements or play significant roles within the family. Sometimes improving the quality of the relationship is the focus, with roots of the problem dating back many years (maybe even generations).
Difficulty Adjusting to a Life Situation1
Sometimes major transitions in the family life cycle, such as childbirth, young adult children leaving home, blending of stepfamilies, or losing a close grandparent may cause tension between members and prompt counseling. Or perhaps the family has gone through a recent hardship, like a death, home or job loss, or divorce. When families cannot effectively adjust their skill sets and interactions to adapt to the transition or cope with the event, tension or conflict may arise.
Coordination of Care
Family therapy may be recommended alongside other mental health treatment. For individuals completing treatment plans for mental health diagnoses such as bipolar disorder or substance use disorder, family therapy may take place as part of their treatment regimen. Family members gain psychoeducation about the disorder and learn what healthy changes can be made in the family patterns. Sometimes families are referred by medical professionals to address developmental problems in children, or they are court mandated to attend due to foster care or CPS involvement.
No matter the reason that you and your family are seeking counseling, with hard work, family therapy can help to improve communication, solve conflicts, and create a better home environment. The above list of reasons for pursuing family therapy is not exhaustive, and there are additional situations in which family therapy is contraindicated or otherwise not recommended. Instances where domestic abuse or violence is present and parents who are high-risk for psychotic episodes are examples. Your therapist will be trained in assessing the risk to your family and making any appropriate referrals or recommendations.
Goals of Family Therapy
The goals of therapy are based upon the reasons that the family initiates counseling. The therapist views you and your loved ones as the experts on your family and with this in mind, will take the time to discuss and ask questions in order to understand what you are hoping to accomplish in treatment. The therapist should also discuss your values and cultural influences, as these factors can impact family rules and child rearing practices.
While the goals for therapy are unique to your family, there are two general overarching goals in family therapy. One is to alleviate the presenting concerning behaviors in the identified patient. The other is to improve the functioning of the family system by decreasing conflict and improving the quality of interactions.
The unique therapy goals for your family may relate to the following areas:
- Strengthening the family as a system
- Strengthening the parental, spousal, or sibling subsystems
- Shifting or altering family roles, rules, triangulations, and alliances
- Restructuring the family hierarchy
- Improving healthy communication between family members
- Increasing individuation amongst members
- Increasing knowledge of generational patterns
- Providing psychoeducation to family members
The therapeutic goals are outlined on a form called a treatment plan, which documents the problems to be addressed and the anticipated interventions to be used in therapy. Ultimately, the goals of family therapy are a collaboration with your therapist and the goals will address dysfunction within the family system by healing mental, emotional, and behavioral problems between members.
Benefits of Family Therapy
Family therapy can be a very effective form of treatment, with many evidence-based approaches in practice today. With successful therapy, the family can learn to improve communication, solve conflict, increase their insight into the family dynamics, and create and sustain a more functional home environment. The family assimilates new coping skills into their repertoire and increases their understanding of one another, forming closer bonds.
Family therapy can at times feel difficult and stressful. To be most effective, one should be open to learning new skills. It is less than helpful to point fingers at others without reflecting on ourselves. Family therapy assists everyone in learning new ways of communicating and interacting, rather than placing blame on certain members. The family system can be enriched in many ways after successful family therapy. Enhanced communication can improve problem solving abilities, reduce tension or conflict, and foster deeper empathy and compassion.
Family members also gain an understanding of family patterns, learn to enforce healthy boundaries, and increase cohesion after trauma or a crisis. Another benefit is the development of a more supportive family environment, where trust and honesty are built, previously isolated members are brought back into the unit, and family members learn to forgive one another.
Types of Family Therapy
There are many different modalities of family therapy. Just as an individual’s behavior is viewed within the family context, the family is viewed within the wider societal context in which it belongs. Family therapists consider the macro forces that impact the family system in order to better meet the needs of the family and identify therapeutic strengths. There are six common approaches to family therapy:
1. Structural Family Therapy1,2
This approach aims to develop healthy familial relationships and resolve conflict by examining the structure, hierarchy, roles, and rules of the family and then restructuring the power differentials that exist in the system. Parents learn how to regain or maintain power, with both adults and children learning how to set appropriate boundaries. The therapist spends time observing and learning about the family in order to join with them. Once they have evaluated the family structure, the therapist recreates circumstances in session that work to restructure the family system by modifying the present, rather than interpreting the past.
2. Strategic Family Therapy1,6,7
With a strategic approach to family therapy, the therapist takes on a more direct style and works with a therapeutic “strategy” in mind. The therapist takes a position of authority with the family, hereby removing power from dominating family members and shifting patterns so that other members who do not hold as much power have the ability to communicate. Outside of the therapy session, homework is assigned. Homework is intended to change how the family members interact by assessing and adjusting the way they work together and make decisions. Strategic therapy is more concerned with how to address the problem, rather than with where and how the problem originated.
3. Multisystemic Therapy (MST)8,9
This is an intensive, community-based treatment program aimed at building healthier families by focusing on the environments of juvenile offenders. A therapist or team of therapists work with the adolescent and their family to increase social and functional behavior in the home, school, and community settings. The strengths of each setting are assessed, and change is facilitated by addressing the individualized issues related to delinquency in each area. Goals of MST include decreasing delinquent youth behavior and out-of-home placement while increasing family cohesion.
5. Narrative Family Therapy1,10
Narrative therapy is the most individualistic approach, and encourages family members to utilize their own strengths when addressing day-to-day problems. Therapy techniques include helping the family construct a narrative of their story, externalizing and deconstructing the problem. The therapist empowers the members by letting them direct conversation and encouraging them to be the experts on their own family.
6. Bowen’s Family Systems Theory1,11
This approach is built on the premise that the family functions as a living being. Changes in the emotional functioning of one family member is balanced by reciprocal changes in the emotional functioning of other members, leading to improvement in emotional functioning for the entire family. Two general goals of this approach are to reduce the presenting symptoms and to increase differentiation in each family member.
There are eight interconnecting, foundational principles to the Bowenian approach:
- Triangles
- Differentiation
- Nuclear family emotional system
- Family projection process
- Multigenerational transmission process
- Emotional cut-off
- Sibling position
- Societal emotional process
No approach to family therapy is directly more beneficial than the others, although some approaches may be better suited for your presenting concerns than others. Ultimately, your family is likely to benefit from therapy if you and the therapist have identified goals and built a safe and trusted rapport. Regardless of the therapeutic model, your therapist should provide ethical and competent treatment, and give each family member respect.
Cost of Family Therapy
How much you pay for family therapy depends greatly on factors such as your insurance coverage and the type of counseling practice in which the therapy takes place. Community mental health agencies may offer sliding scale options available for anyone paying out of pocket.
When you set up the initial appointment, you may find it helpful to ask about the cost of your therapy. You can also get information about your coverage for therapy from your insurance company if you have questions.
How to Find a Family Therapist
You will likely be able to find a family therapist near your area. You can narrow your searches online by using the LMFT acronym, which stands for Licensed Marriage and Family Therapist. As noted above, not all family therapists have a LMFT license and this license title also varies from state to state (for example, clinicians with this license in the state of Maryland have a LCMFT, which stands for Licensed Clinical Marriage and Family Therapist).4
The AAMFT website can connect you to licensed therapists by using their Therapist Locator.5 Spend time browsing online clinical profiles or websites to find the therapist and practice that feels like the right fit for you.
Who Is Qualified to Provide Family Therapy?
Family therapists are mental health professionals with clinical training and supervision in the assessment and treatment of the family system. They are knowledgeable on family theory and intervention techniques while also possessing the skills to navigate therapy sessions that balance everyone’s needs.
Many have a graduate degree in couple, marriage, and family counseling/therapy, or related field such as psychology, social work, or counseling. They could be licensed as a marriage and family therapist, professional counselor, or social worker, and may have a postgraduate certificate or training. Some family therapists are credentialed by the American Association for Marriage and Family Therapy (AAMFT).3
When searching for a family therapist, pay attention to the educational background, training, and professional experience listed in their online bio to gain a sense of their qualifications. If you have any questions about the therapist or their approach to family therapy, feel free to ask them in the first session.
What to Expect at Your First Appointment
Family therapy is considered to be a brief modality, with treatment generally lasting between 12-20 sessions. The frequency and length of sessions depends on your family’s needs and the therapist’s recommendation. In some family therapy programs, a therapist or team of therapists may audio or video record the sessions and review them for clinical purposes.
The cost of family therapy sessions varies between providers and settings. Your private insurance and whether the provider is in-network are variables that affect your out of pocket costs. Community mental health agencies often take Medicaid and may provide sliding fees for those without insurance.
The first session is the intake assessment. The therapist will want to meet with all family members who play a pivotal role in the presenting concern. This usually includes members living in the home and may extend to relatives who do not. During the intake, the therapist will spend time asking your family questions so that they can understand why you are coming in and how they can help. Details about your presenting concerns, family history, family strengths, and current coping tactics are pertinent information.
Your therapist will also assess the diverse intersections of each person’s identity, such as sexual orientation, gender identity, race, ethnicity, socio-economic status, and religion when contextualizing family dynamics. The larger societal systems of oppression that impact the family, such as racism, sexism, classism, or ableism, should also be explored in order for the therapist to fully understand the systemic context of the family. Certain details about the assessment, like the length of time the intake lasts, the number of sessions required to complete the intake, and the type of assessment that is used are all details that can vary depending on the family therapy approach and the setting.
Informed consent is also done in the first session and is a conversation the therapist initiates that provides you with information about their credentials and qualifications, theoretical orientation, and limits of confidentiality. If you have questions be sure to bring them to your therapist’s attention, as your comfortability and full understanding of the therapy process in which you are about to engage is of the utmost importance.
The Process of Family Therapy
Various, multi-layered dynamics are brought into the therapy room when the whole family is present, and the tone of the room may at times feel intimidating or overwhelming. Family therapists are trained to navigate these situations, so they become learning opportunities that lead to healthier interactions, rather than further breakdowns in emotional bonds.
In family therapy, the family is the client, and your therapist acts as a family advocate. Your therapist will avoid forming alliances or becoming involved in triangles with family members and will ensure a non-judgmental atmosphere that promotes trust.
A family therapist focuses more on the counseling process rather than on talk therapy alone. Your therapist will encourage family members to interact and talk with each other. They view these interactions as opportunities to assist the family in shaping new, healthier communication patterns. Interventions from cognitive, behavioral, and interpersonal therapies can be adapted for family therapy.
Family therapists often use activities or exercises in session to engage family interaction. A common activity that your family might be asked is to create a genogram, which is an illustrative representation of a family tree that includes information about the members and relationships between them.1 Descriptive information such as names, gender, marriage and divorce dates, birthdates, and dates of death if applicable are included.
You can find additional information about education, occupation, illness, adoption, foster care involvement, reproductive loss, addiction, abuse, and living arrangements between members. Genograms also depict social and emotional connections, including alliances, triangles, or cut off. The family and therapist discuss the genogram to learn more about the history and generational patterns that may be shaping emotional and behavioral problems in the present. They can also be a great way to facilitate conversations with your children about difficult topics, like telling your child they’re adopted.
Conclusion
Family members are intricately connected to each other by the dynamics of the family system. With hard work and the help of your therapist, family therapy can help those in distress and who want to improve the quality of their relationships. At the end of the day, your family will likely find family therapy to be an enriching endeavor, in which you and your loved ones learned how to work together to overcome difficult situations and achieve closer bonds.
