MANAGING THE TROUBLED FAMILY

More than one member of the family is seen together in family therapy- thus the family transcends the individual in family therapy.

The vivid impact of face-to-face interactions is one of the major assets of the family therapy session or interview. The family therapist moves quickly into the living space of the family as the members draw the therapist as a participant into the whirlpool of their anxiety ridden struggles. The primary responsibility of the therapist is to mobilize a useful quality of empathy and communication, and to arouse and enhance a live and meaningful emotional interaction between family members. As the members feel in touch with the therapist, they come into better touch with one another. Through the quality of the use of self by the therapist and an open and earnest sharing of own feelings and attitudes, the therapist sets an example for the needed sincerity of interaction between family members.

Sometimes, the whole family is pervaded by a mood of disillusionment, defeat and depression. Even so, there is always a flicker of hope. It is the responsibility of the therapist to nourish this hope and to build faith that the family may achieve something better together.

The clinical interview is the main instrument for obtaining relevant information. The kind of information obtained depends to a large extent on how the information is sought. Each level of entry into the inner life of the family offers selective access to some components of family experience and may obscure other components for the moment.

In the first contact with a troubled family, it is preferable to initiate the process in a unprejudiced, non pre-determined or biased manner. Whatever the presenting complaint and regardless of which member is labeled the “sick” or “problem” member, the whole family is invited to come and talk it over.

Families are usually seen once a week, though occasionally, the frequency of contact may be earlier. Each session lasts for about an hour. At the outset, the family may be troubled and perplexed, frenetic or panicky. The members realize that something has gone wrong, but are not able to figure out how and why, or what to do about it. Traditionally, families push one person forward as the fall person- the sick or problem person. Yet, in reality, often several and sometimes all of the members are disturbed, although in different ways and to differing degrees. What the family therapist faces is a cluster of interrelated processes of illness, and not a single “patient”.

In many families, regardless of the symptoms, there is no urge for referral to therapeutic services as long as the family role relationships are held in tolerable balance. The timing of the demand for professional help strongly coincides with the immediate, dramatic impact of a deterioration of the previous state of balance, which brings in its wake a distressing family conflict.

In family interviews, what one member conceals, the other member reveals. What the parents together hide, the child may reveal. What one member expresses in a twisted prejudiced way is corrected by another member. When certain anxiety filled areas are touched upon, the family may engage in a silent pact to avoid discussing those areas. Sooner or later, such denials are broken through.

In this process, the therapist includes her/his knowledge and use of self in a special way. The therapist is a participant observer, active, open, fluid, forthright and sometimes blunt. The therapist moves directly into the family conflict to energize and influence the interactional processes, withdraws to have an objective view of her/his views, to survey and assess significant events and then moves back in again. Weighing and balancing the healthy and the sick emotional forces, the therapist supports healthy views and counteracts sickness by shifting her/his function at changing phases of the family therapy process.

The responsibilities of the therapist are many and complex; they require a flexible, open and non defensive use of self. The family and its parts interact with, absorb and use her/his influence in a variety of ways. Depending on the shifting foci of conflict and anxiety, one or another member joins with and separates from particular elements of the identity of the therapist.

The therapist must move her/his influence from one part of the family to another following the shifting core of the most destructive conflict. In this way, s(h)e, stimulates an expanding awareness of the true nature of the emotional and social disorders of the family unit and engages the members in a progressive process of working through the related conflicts.

Family therapy begins promptly with the face-to-face contact. The therapist makes instantaneous observations of the personalities of the family members, their ways of interaction and their adaptation to family roles. How do they enter, who sits next to whom, who looks towards whom, who looks away from whom, who speaks, who listens, who smiles, who frowns all provide valuable clues to the therapist. At a typical session, the family arrives in a state of pent up anger, pain, fear and thwarted need. The therapist quickly senses the emotional climate and observes the quality of appeal that the members project to one another and to the therapist. Who wants what from whom? Do they deny and disguise their needs or express them in urgent, frantic ways? Do they simply give up, and in a mood of resigned apathy, cease to ask or expect anything? The therapist has to note the existing confusion, distrust and hostile fragmentation of family relationships.

In an overall view, the therapeutic orientation maybe characterized thus: the therapist discovers the idiosyncratic language of the family, how the members talk, what they choose to talk about, and very importantly, what they tacitly avoid. The therapist makes rapid note of what is felt and communicated below the level of words in body language, facial expressions, inarticulate gestures and postural avoidances. The therapist evaluates the outer face of the family-its protective mask. Therapist perceives and assesses the deeper currents of emotions that the family members fear, the inhibitions, the fright, mistrust and despair, the bitterness and vindictiveness. The therapist identifies those forces of conflict and anxiety which freeze the reaching out of members, the asking for closeness and understanding, each with the therapist and with one another.

Stage by stage, as the therapist strips away denials, displacements, rationalizations and other disguises, the essential conflicts between and within family members come into clearer perspectives. Acting as a catalyst, the therapist provokes increasingly candid disclosures of underlying currents of interpersonal conflict. In a progressive working through of the elements of conflict, and through a process of consensual validation, significant connections can be traced between the family disorder and the intra psychic anxieties and disablements of its individual members.

As therapy proceeds, the sense of tension and danger often mounts. The family experiences an increasing threat of loss of control. The calm and firm presence of the therapist must offer the needed assurance against family catastrophe.

The function of the family therapist as a controller of interpersonal danger is but one phase of her/his role as a true parent figure. In this position, the therapist offers security and emotional support, acceptance, understanding, affirmation of worth and direct satisfaction of valid emotional needs.  Therapist catalyses the interactions among the family members towards cooperation in the quest for solutions to conflict or toward finding more appropriate compromises. Along this path, the therapist activates a shift towards improving mutual complementing of needs.

In a troubled family group, there is an aggravated clash of competing identities and values. This competition is expressed in ongoing contest of needs, identities and value representations between parental partners, which in turn can be traced to the links of identity and values of each member with the respective family of origin.

In summary, the family therapist functions include

1. Establishing a useful rapport, empathy and communication among family members- between members and with the therapist
2. Utilizing the rapport to evoke expression of major conflicts and ways of coping. Therapist classifies conflict by dissolving barriers, defenses, confusions and misunderstandings. Attempts are made, in stages,  to bring the family to a mutual and more accurate understanding of what is really wrong. This aim is achieved through a series of interventions.
   1. Countering inappropriate denials, displacements and rationalizations of conflict
   2. Transforming concealed or dormant interpersonal conflicts into open interactional expression
   3. Lifting hidden interpersonal conflict to the level of interpersonal interaction
   4. Fulfilling, in part, the role of a true parent figure- a controller of danger and a source of emotional support and satisfaction- supplying elements that the family needs but lacks. The emotional nurturing of the family that is provided by the therapist is a kind of substitutive therapy.
   5. Introduces more appropriate attitudes, emotions and images of family relationships than the family has ever had.
   6. Work towards penetrating and undermining resistances and reducing the intensity of shared currents of conflict, guilt and fear. The therapist accomplishes these aims mainly by the use of confrontation and interpretation
   7. The therapist serves as a personal instrument of reality testing for the family
   8. The therapist serves as an educator and personifies of useful modes of family health.

Indications of family therapy

1. When child/adolescent is the referred client
2. When family members define a problem as a family issue
3. When relationships affect children/couples
4. When family has experienced recent stress
5. When psychological symptoms have secondary gain effects
6. When family members become organized into helping with the problem

Contraindications of family therapy

1. When significant family members are not available
2. Family therapy is viewed as a forced alternative to legal proceedings for separation
3. When the family presents “too late”
4. Where medication might be a more appropriate form of therapy
5. Circumstances of precarious emotional equilibrium/emotional deprivation.