Interpersonal Therapy

Definition

Purpose

Precautions

Description

Aftercare

Normal results

Abnormal results

Resources

Definition

Interpersonal therapy (IPT) is a short-term supportive psychotherapy that focuses on the connection between interactions between people and the development of a person’spsychiatric symptoms.

Purpose

Interpersonal therapy was initially developed to treat adult depression. It has since been applied to the treatment of depression in adolescents, the elderly, and people with Human Immunodeficiency Virus (HIV) infection. There is an IPT conjoint (couple) therapy for people whose marital disputes contribute to depressive episodes. IPT has also been modified for the treatment of a number of disorders, including substance abuse ; bulimia and anorexia nervosa; bipolar disorder ; and dysthymia. Research is underway to determine the efficacy of IPT in the treatment of patients with panic disorder or borderline personality disorder ; depressed caregivers of patients with traumatic brain injuries; depressed pregnant women; and people suffering from protracted bereavement.

Interpersonal therapy is a descendant of psycho-dynamic therapy, itself derived from psychoanalysis , with its emphasis on the unconscious and childhood experiences. Symptoms and personal difficulties are regarded as arising from deep, unresolved personality or character problems. Psychodynamic psychotherapy is a long-term method of treatment, with in-depth exploration of past family relationships as they were perceived during the client’sinfancy, childhood, and adolescence.

There are seven types of interventions that are commonly used in IPT, many of which reflect the influence of psychodynamic psychotherapy: a focus on clients’ emotions; an exploration of clients’ resistance to treatment; discussion of patterns in clients’ relationships and experiences; taking a detailed past history; an emphasis on clients’ current interpersonal experiences; exploration of the therapist/client relationship; and the identification of clients’ wishes and fantasies. IPT is, however, distinctive for its brevity and its treatment focus. IPT emphasizes the ways in which a person’s current relationships and social context cause or maintain symptoms rather than exploring the deep-seated sources of the symptoms. Its goals are rapid symptom reduction and improved social adjustment. A frequent byproduct of IPT treatment is more satisfying relationships in the present.

IPT has the following goals in the treatment of depression: to diagnose depression explicitly; to educate the client about depression, its causes, and the various treatments available for it; to identify the interpersonal context of depression as it relates to symptom development; and to develop strategies for the client to follow in coping with the depression. Because interpersonal therapy is a short-term approach, the therapist addresses only one or two problem areas in the client’s current functioning. In the early sessions, the therapist and client determine which areas would be most helpful in reducing the client’s symptoms. The remaining sessions are then organized toward resolving these agreed-upon problem areas. This time-limited framework distinguishes IPT from therapies that are open-ended in their exploration. The targeted approach of IPT has demonstrated rapid improvement for patients with problems ranging from mild situational depression to severe depression with a recent history of suicide attempts.

Interpersonal therapy has been outlined in a manual by Klerman and Weissman, which ensures some standardization in the training of interpersonal therapists and their practice. Because of this standardized training format, IPT is not usually combined with other talk therapies. Treatment with IPT, however, is often combined with drug therapy, particularly when the client suffers from such mood disorders as depression, dysthymia, or bipolar disorder.

Precautions

Training programs in interpersonal therapy are still not widely available, so that many practicing therapists base their work on the manual alone without additional supervision. It is unclear whether reading the manual alone is sufficient to provide an acceptable standard of care.

While interpersonal therapy has been adapted for use with substance abusers, it has not demonstrated its effectiveness with this group of patients. Researchers studying patients addicted to opiates or cocaine found little benefit to incorporating IPT into the standard recovery programs. These findings suggest that another treatment method that offers greater structure and direction would be more successful with these patients.

Description

Since the interpersonal therapy model was developed for the treatment of depression and then modified for use with other populations and mental disorders, an understanding of IPT’s approach to depression is crucial. Interpersonal therapists focus on the functional role of depression rather than on its etiology or cause; and they look at the ways in which problematic interactions develop when a person becomes depressed. The IPT framework considers clinical depression as having three components: the development of symptoms, which arise from biological, genetic and/or psychodynamic processes; social interactions with other people, which are learned over the course of one’s life; and personality, made up of the more enduring traits and behaviors that may predispose a person to depressive symptoms. IPT intervenes at the levels of symptom formation and social functioning, and does not attempt to alter aspects of the client’s personality.

Subtypes of IPT

Interpersonal therapy offers two possible treatment plans for persons with depressive disorders. The first plan treats the acute episode of depression by eliminating the current depressive symptoms. This approach requires intervening while the person is in the midst of a depression. The acute phase of treatment typically lasts 2-4 months with weekly sessions. Many clients terminate treatment at that point, after their symptoms have subsided. Maintenance treatment (IPT-M) is the second treatment plan and is much less commonly utilized than acute treatment. IPT-M is a longer-term therapy based on the principles of interpersonal therapy but with the aim of preventing or reducing the frequency of further depressive episodes. Some clients choose IPT-M after the acute treatment phase. IPT-M can extend over a period of 2-3 years, with therapy sessions once a month.

Psychoeducation in IPT

Treatment with IPT is based on the premise that depression occurs in a social and interpersonal context that must be understood for improvement to occur. In the first session, the psychiatric history includes a review of the client’s current social functioning and current close relationships, their patterns and their mutual expectations. Changes in relationships prior to the onset of symptoms are clarified, such as the death of a loved one, a child leaving home, or worsening marital conflict.

IPT is psychoeducational in nature to some degree. It involves teaching the client about the nature of depression and the ways that it manifests in his or her life and relationships. In the initial sessions, depressive symptoms are reviewed in detail, and the accurate naming of the problem is essential. The therapist then explains depression and its treatment and may explain to the client that he or she has adopted the “sick role.” The concept of the “sick role” is derived from the work of a sociologist named Talcott Parsons, and is based on the notion that illness is not merely a condition but a social role that affects the attitudes and behaviors of the client and those around him or her. Over time, the client comes to see that the sick role has increasingly come to govern his or her social interactions.

Identification of problem areas

The techniques of IPT were developed to manage four basic interpersonal problem areas: unresolved grief; role transitions; interpersonal role disputes (often marital disputes); and interpersonal deficits (deficiencies). In the early sessions, the interpersonal therapist and the client attempt to determine which of these four problems is most closely associated with the onset of the current depressive episode. Therapy is then organized to help the client deal with the interpersonal difficulties in the primary problem area. The coping strategies that the client is encouraged to discover and employ in daily life are tailored to his or her individual situation.

UNRESOLVED GRIEF

In normal bereavement, a person experiences symptoms such as sadness, disturbed sleep, and difficulty functioning but these usually resolve in 2-4 months. Unresolved grief in depressed people is usually either delayed grief, which has been postponed and then experienced long after the loss; or distorted grief, in which there is no felt emotion of sadness but there may be nonemotional symptoms, often physical. If unresolved grief is identified as the primary issue, the goals of treatment are to facilitate the mourning process. Successful therapy will help the client re-establish interests and relationships that can begin to fill the void of what has been lost.

ROLE DISPUTES

Interpersonal role disputes occur when the client and at least one other significant person have differing expectations of their relationship. The IPT therapist focuses on these disputes if they seem stalled or repetitious, or offer little hope of improvement. The treatment goals include helping the client identify the nature of the dispute; decide on a plan of action; and begin to modify unsatisfying patterns, reassess expectations of the relationship, or both. The therapist does not direct the client to one particular resolution of difficulties and should not attempt to preserve unworkable relationships.

ROLE TRANSITIONS

Depression associated with role transitions occurs when a person has difficulty coping with life changes that require new roles. These may be such transitions as retirement, a career change, moving, or leaving home. People who are clinically depressed are most likely to experience role changes as losses rather than opportunities. The loss may be obvious, as when a marriage ends, or more subtle, as the loss of freedom people experience after the birth of a child. Therapy is terminated when a client has given up the old role; expressed the accompanying feelings of guilt, anger, and loss; acquired new skills; and developed a new social network around the new role.

INTERPERSONAL DEFICITS

Interpersonal deficits are the focus of treatment when the client has a history of inadequate or unsupportive interpersonal relationships. The client may never have established lasting or intimate relationships as an adult, and may experience a sense of inadequacy, lack of self-assertion, and guilt about expressing anger. Generally, clients with a history of extreme social isolation come to therapy with more severe emotional disturbances. The goal of treatment is to reduce the client’s social isolation. Instead of focusing on current relationships, IPT therapy in this area focuses on the client’spast relationships; the present relationship with the therapist; and ways to form new relationships.

IPT in special populations

ELDERLY CLIENTS

In translating the IPT model of depression to work with different populations, the core principles and problem areas remain essentially the same, with some modifications. In working with the elderly, IPT sessions may be shorter to allow for decreased energy levels, and dependency issues may be more prominent. In addition, the therapist may work with an elderly client toward tolerating rather than eliminating long-standing role disputes.

CLIENTS WITH HIV INFECTION

In IPT with HIV-positive clients, particular attention is paid to the clients’ unique set of psychosocial stressors: the stigma of the disease; the effects of being gay (if applicable); dealing with family members who may isolate themselves; and coping with the medical consequences of the disease.

ADOLESCENTS

In IPT with adolescents, the therapist addresses such common developmental issues as separation from parents; the client’sauthority in relationship to parents; the development of new interpersonal relationships; first experiences of the death of a relative or friend; peer pressure; and single-parent families. Adolescents are seen weekly for 12 weeks with once-weekly additional phone contact between therapist and client for the first four weeks of treatment.

The parents are interviewed in the initial session to get a comprehensive history of the adolescent’s symptoms, and to educate the parents as well as the young person about depression and possible treatments, including a discussion of the need for medication. The therapist refrains from giving advice when working with adolescents, and will primarily use supportive listening, while assessing the client for evidence of suicidal thoughts or problems with school attendance. So far, research does not support the efficacy of anti-depressant medication in treating adolescents, though most clinicians will give some younger clients a trial of medication if it appears to offer relief.

CLIENTS WITH SUBSTANCE ABUSE DISORDERS

While IPT has not yet demonstrated its efficacy in the field of substance abuse recovery, a version of IPT has been developed for use with substance abusers. The two goals are to help the client stop or cut down on drug use; and to help the client develop better strategies for dealing with the social and interpersonal consequences of drug use. To meet these goals, the client must accept the need to stop; take steps to manage impulsiveness; and recognize the social contexts of drug purchase and use. Relapse is viewed as the rule rather than the exception in treating substance abuse disorders, and the therapist avoids treating the client in a punitive or disapproving manner when it occurs. Instead, the therapist reminds the client of the fact that staying away from drugs is the client’s decision.

CLIENTS WITH EATING DISORDERS

IPT has been extended to the treatment of eating disorders. The IPT therapist does not focus directly on the symptoms of the disorder, but rather, allows for identification of problem areas that have contributed to the emergence of the disorder over time. IPT appears to be useful in treating clients with bulimia whose symptoms are maintained by interpersonal issues, including social anxiety ; sensitivity to conflict and rejection; and difficulty managing negative emotions. IPT is helpful in bringing the problems underlying the bingeing and purging to the surface, such as conflict avoidance; difficulties with role expectations; confusion regarding needs for closeness and distance; and deficiencies in solving social problems. IPT also helps people with bulimia to regulate the emotional states that maintain the bulimic behavior.

Anorexia nervosa also appears to be responsive to treatment with IPT. Research indicates that there is a connection between interpersonal and family dysfunction and the development of anorexia nervosa. Therapists disagree as to whether interpersonal dysfunction causes or is caused by anorexia. IPT has been helpful because it is not concerned with the origin but rather seeks to improve the client’sinterpersonal functioning and thereby decreasing symptoms. IPT’s four categories of grief, interpersonal disputes, interpersonal deficits, and role transitions correspond to the core issues of clients with anorexia. Social phobia is another disorder that responds well to IPT therapy.

Aftercare

Interpersonal therapy as a maintenance approach (IPT-M) could be viewed as aftercare for clients suffering from depression. It is designed as a preventive measure by focusing on the period after the acute depression has passed. Typically, once the client is in remission and is symptom-free, he or she takes on more responsibilities and has increased social contact. These changes can lead to increased stress and greater vulnerability to another episode of depression. IPT-M enables clients to reduce the stresses associated with remission and thereby lower the risk of recurrence. The goal of maintenance therapy is to keep the client at his or her current level of functioning. Research has shown that for clients with a history of recurrent depression, total prevention is unlikely, but that maintenance therapy may delay a recurrence.

In general, long-term maintenance psychotherapy by itself is not recommended unless there are such reasons as pregnancy or severe side effects that prevent the client from being treated with medication. IPT-M does, however, seem to be particularly helpful with certain groups of patients, either alone or in combination with medication. Women appear to benefit, due to the importance of social environment and social relations in female gender roles; the effects of the menstrual cycle on symptoms; and complications related to victimization by rape, incest, or battering. IPT is also useful for elderly clients who can’t take antidepressants due to intolerable side effects or such medical conditions as autoimmune disorders, cardiovascular disorders, diabetes, or other general medical conditions.

Normal results

The expected outcomes of interpersonal therapy are a reduction or the elimination of symptoms and improved interpersonal functioning. There will also be a greater understanding of the presenting symptoms and ways to prevent their recurrence. For example, in the case of depression, a person will have been educated about the nature of depression; what it looks like for him or her; and the interpersonal triggers of a

KEY TERMS

Bereavement —The emotional experience of loss after the death of a friend or relative.

Bingeing —An excessive amount of food consumed in a short period of time. Usually, while a person binge eats, he or she feels disconnected from reality, and feels unable to stop. The bingeing may temporarily relieve depression or anxiety, but after the binge, the person usually feels guilty and depressed.

Dysthymia —Depression of low intensity.

Dysthymic disorder —A mood disorder that is less severe than depression but usually more chronic.

Etiology —The cause or origin of a disease or disorder. The word is also used to refer to the study of the causes of disease.

Psychosocial —A term that refers to the emotional and social aspects of psychological disorders.

Purging —Inappropriate actions taken to prevent weight gain, often after bingeing, including self-induced vomiting or the misuse of laxatives, diuretics, enemas, or other medications.

Remission —In the course of an illness or disorder, a period of time when symptoms are absent.

Role —The set of customary or expected behavior patterns associated with a particular position or function in society. For example, a person’s role as mother is associated with one set of expected behaviors, and her role as a worker with a very different set.

Role transition —Life changes that require an alteration in one’s social or occupational status or self-image.

Stigma —A mark or characteristic trait of a disease or defect; by extension, a cause for reproach or a stain on one’s reputation. Such sexually transmitted diseases as HIV infection carry a severe social stigma.

Supportive —An approach to psychotherapy that seeks to encourage the patient or offer emotional support to him or her, as distinct from insight-oriented or exploratory approaches to treatment.

depressive episode. A person will also leave therapy with strategies for minimizing triggers and for resolving future depressive episodes more effectively. While interpersonal therapy focuses on the present, it can also improve the client’sfuture through increased awareness of preventive measures and strengthened coping skills.

Abnormal results

Research has shown that IPT requires clients’ commitment to therapy prior to starting the treatment. If clients are resistant to an educational approach, the results of IPT are generally poor. It has been found that when people do not accept IPT’s methods and approach at the outset; they are unlikely to be convinced over the course of therapy and they receive little benefit from treatment. IPT clients appear to do better in therapy if they have confidence in their therapist; therefore, if the initial fit between therapist and client is not good, therapy will often be unsuccessful. A client should listen to his or her instincts early in treatment, and either seek out another interpersonal therapist or find a therapist who uses a different approach—such as cognitive-behavioral therapy , which was also developed specifically for the treatment of depression.

See alsoBulimia nervosa; Gender issues in mental health; Grief; Major depressive disorder.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Klerman, Gerald L., and others. Interpersonal Psychotherapy of Depression. New York: Basic Books, Inc., 1984.

Mufson, Laura, Ph.D. Interpersonal Psychotherapy for Depressed Adolescents. New York: Guilford Press, 1993.

Klerman, Gerald L., M.D., and Myrna M. Weissman, Ph.D., eds. New Applications of Interpersonal Psychotherapy. Washington, D.C.: American Psychiatric Press, Inc., 1993.

PERIODICALS

Apple, Robin F. “Interpersonal Therapy for Bulimia Nervosa.” JCLP/In Session: Psychotherapy in Practice 55, no. 6 (1999): 715–725.

Barkham, Michael, and Gillian E. Hardy. “Counselling and interpersonal therapies for depression: towards securing an evidence-base.” British Medical Bulletin 57 (2001): 115–132.

Frank, Ellen, Ph.D., and Michael E. Thase, M.D. “Natural History and Preventative Treatment of Recurrent Mood Disorders.” Annual Reviews Medicine 50 (1999): 453–468.

House, Allan, D. M. “Brief psychodynamic interpersonal therapy after deliberate self-poisoning reduced suicidal ideation and deliberate self-harm.” ACP Journal Club 136 (January/February 2002): 27.

McIntosh, Virginia V. “Interpersonal Psychotherapy for Anorexia Nervosa.” International Journal of Eating Disorders 27 (March 2000): 125–139.

Mufson, Laura, Ph.D., and others. “Efficacy of Interpersonal Psychotherapy for Depressed Adolescents.” Archives of General Psychiatry 56, no. 6 (June 1999): 573-579. Weissman, Myrna M., Ph.D., and John C. Markowitz, M.D.

“Interpersonal Psychotherapy: Current Status.” Archives of General Psychiatry 51, no. 8 (August 1994): 599–606.

ORGANIZATIONS

International Society for Interpersonal Psychotherapy. c/o Myrna M. Weissman, Columbia University, 1051 Riverside Drive, Unit 24, New York, NY 10032. <http://interpersonalpsychotherapy.org>.

Holly Scherstuhl, M.Ed.

Interpersonal therapy

Definition

Interpersonal therapy (IPT) is a short-term supportive psychotherapy that focuses on the connection between interactions between people and the development of a person's psychiatric symptoms.

Purpose

Interpersonal therapy was initially developed to treat adult depression. It has since been applied to the treatment of depression in adolescents, the elderly, and people with Human Immunodeficiency Virus (HIV) infection. There is an IPT conjoint (couple) therapy for people whose marital disputes contribute to depressive episodes. IPT has also been modified for the treatment of a number of disorders, including substance abuse; bulimia and anorexia nervosa ; bipolar disorder ; and dysthymia. Research is underway to determine the efficacy of IPT in the treatment of patients with panic disorder or borderline personality disorder ; depressed caregivers of patients with traumatic brain injuries; depressed pregnant women; and people suffering from protracted bereavement.

Interpersonal therapy is a descendant of psychodynamic therapy, itself derived from psychoanalysis , with its emphasis on the unconscious and childhood experiences. Symptoms and personal difficulties are regarded as arising from deep, unresolved personality or character problems. Psychodynamic psychotherapy is a long-term method of treatment, with in-depth exploration of past family relationships as they were perceived during the client's infancy, childhood, and adolescence.

There are seven types of interventions that are commonly used in IPT, many of which reflect the influence of psychodynamic psychotherapy: a focus on clients' emotions; an exploration of clients' resistance to treatment; discussion of patterns in clients' relationships and experiences; taking a detailed past history; an emphasis on clients' current interpersonal experiences; exploration of the therapist/client relationship; and the identification of clients' wishes and fantasies. IPT is, however, distinctive for its brevity and its treatment focus. IPT emphasizes the ways in which a person's current relationships and social context cause or maintain symptoms rather than exploring the deep-seated sources of the symptoms. Its goals are rapid symptom reduction and improved social adjustment. A frequent byproduct of IPT treatment is more satisfying relationships in the present.

IPT has the following goals in the treatment of depression: to diagnose depression explicitly; to educate the client about depression, its causes, and the various treatments available for it; to identify the interpersonal context of depression as it relates to symptom development; and to develop strategies for the client to follow in coping with the depression. Because interpersonal therapy is a short-term approach, the therapist addresses only one or two problem areas in the client's current functioning. In the early sessions, the therapist and client determine which areas would be most helpful in reducing the client's symptoms. The remaining sessions are then organized toward resolving these agreed-upon problem areas. This time-limited framework distinguishes IPT from therapies that are open-ended in their exploration. The targeted approach of IPT has demonstrated rapid improvement for patients with problems ranging from mild situational depression to severe depression with a recent history of suicide attempts.

Interpersonal therapy has been outlined in a manual by Klerman and Weissman, which ensures some standardization in the training of interpersonal therapists and their practice. Because of this standardized training format, IPT is not usually combined with other talk therapies. Treatment with IPT, however, is often combined with drug therapy, particularly when the client suffers from such mood disorders as depression, dysthymia, or bipolar disorder.

Precautions

Training programs in interpersonal therapy are still not widely available, so that many practicing therapists base their work on the manual alone without additional supervision. It is unclear whether reading the manual alone is sufficient to provide an acceptable standard of care.

While interpersonal therapy has been adapted for use with substance abusers, it has not demonstrated its effectiveness with this group of patients. Researchers studying patients addicted to opiates or cocaine found little benefit to incorporating IPT into the standard recovery programs. These findings suggest that another treatment method that offers greater structure and direction would be more successful with these patients.

Description

Since the interpersonal therapy model was developed for the treatment of depression and then modified for use with other populations and mental disorders, an understanding of IPT's approach to depression is crucial. Interpersonal therapists focus on the functional role of depression rather than on its etiology or cause, and they look at the ways in which problematic interactions develop when a person becomes depressed. The IPT framework considers clinical depression as having three components: the development of symptoms, which arise from biological, genetic and/or psychodynamic processes; social interactions with other people, which are learned over the course of one's life; and personality, made up of the more enduring traits and behaviors that may predispose a person to depressive symptoms. IPT intervenes at the levels of symptom formation and social functioning, and does not attempt to alter aspects of the client's personality.

Subtypes of IPT

Interpersonal therapy offers two possible treatment plans for persons with depressive disorders. The first plan treats the acute episode of depression by eliminating the current depressive symptoms. This approach requires intervening while the person is in the midst of a depression. The acute phase of treatment typically lasts two to four months with weekly sessions. Many clients terminate treatment at that point, after their symptoms have subsided. Maintenance treatment (IPT-M) is the second treatment plan and is much less commonly utilized than acute treatment. IPT-M is a longer-term therapy based on the principles of interpersonal therapy but with the aim of preventing or reducing the frequency of further depressive episodes. Some clients choose IPT-M after the acute treatment phase. IPT-M can extend over a period of two to three years, with therapy sessions once a month.

Psychoeducation in IPT

Treatment with IPT is based on the premise that depression occurs in a social and interpersonal context that must be understood for improvement to occur. In the first session, the psychiatric history includes a review of the client's current social functioning and current close relationships, their patterns and their mutual expectations. Changes in relationships prior to the onset of symptoms are clarified, such as the death of a loved one, a child leaving home, or worsening marital conflict.

IPT is psychoeducational in nature to some degree. It involves teaching the client about the nature of depression and the ways that it manifests in his or her life and relationships. In the initial sessions, depressive symptoms are reviewed in detail, and the accurate naming of the problem is essential. The therapist then explains depression and its treatment and may explain to the client that he or she has adopted the "sick role." The concept of the "sick role" is derived from the work of a sociologist named Talcott Parsons, and is based on the notion that illness is not merely a condition but a social role that affects the attitudes and behaviors of the client and those around him or her. Over time, the client comes to see that the sick role has increasingly come to govern his or her social interactions.

Identification of problem areas

The techniques of IPT were developed to manage four basic interpersonal problem areas: unresolved grief ; role transitions; interpersonal role disputes (often marital disputes); and interpersonal deficits (deficiencies). In the early sessions, the interpersonal therapist and the client attempt to determine which of these four problems is most closely associated with the onset of the current depressive episode. Therapy is then organized to help the client deal with the interpersonal difficulties in the primary problem area. The coping strategies that the client is encouraged to discover and employ in daily life are tailored to his or her individual situation.

UNRESOLVED GRIEF. In normal bereavement, a person experiences symptoms such as sadness, disturbed sleep, and difficulty functioning but these usually resolve in two to four months. Unresolved grief in depressed people is usually either delayed grief, which has been postponed and then experienced long after the loss; or distorted grief, in which there is no felt emotion of sadness but there may be nonemotional symptoms, often physical. If unresolved grief is identified as the primary issue, the goals of treatment are to facilitate the mourning process. Successful therapy will help the client re-establish interests and relationships that can begin to fill the void of what has been lost.

ROLE DISPUTES. Interpersonal role disputes occur when the client and at least one other significant person have differing expectations of their relationship. The IPT therapist focuses on these disputes if they seem stalled or repetitious, or offer little hope of improvement. The treatment goals include helping the client identify the nature of the dispute; decide on a plan of action; and begin to modify unsatisfying patterns, reassess expectations of the relationship, or both. The therapist does not direct the client to one particular resolution of difficulties and should not attempt to preserve unworkable relationships.

ROLE TRANSITIONS. Depression associated with role transitions occurs when a person has difficulty coping with life changes that require new roles. These may be such transitions as retirement, a career change, moving, or leaving home. People who are clinically depressed are most likely to experience role changes as losses rather than opportunities. The loss may be obvious, as when a marriage ends, or more subtle, as the loss of freedom people experience after the birth of a child. Therapy is terminated when a client has given up the old role; expressed the accompanying feelings of guilt, anger, and loss; acquired new skills; and developed a new social network around the new role.

INTERPERSONAL DEFICITS. Interpersonal deficits are the focus of treatment when the client has a history of inadequate or unsupportive interpersonal relationships. The client may never have established lasting or intimate relationships as an adult, and may experience a sense of inadequacy, lack of self-assertion, and guilt about expressing anger. Generally, clients with a history of extreme social isolation come to therapy with more severe emotional disturbances. The goal of treatment is to reduce the client's social isolation. Instead of focusing on current relationships, IPT therapy in this area focuses on the client's past relationships; the present relationship with the therapist; and ways to form new relationships.

IPT in special populations

ELDERLY CLIENTS. In translating the IPT model of depression to work with different populations, the core principles and problem areas remain essentially the same, with some modifications. In working with the elderly, IPT sessions may be shorter to allow for decreased energy levels, and dependency issues may be more prominent. In addition, the therapist may work with an elderly client toward tolerating rather than eliminating long-standing role disputes.

CLIENTS WITH HIV INFECTION. In IPT with HIV-positive clients, particular attention is paid to the clients' unique set of psychosocial stressors: the stigma of the disease; the effects of being gay (if applicable); dealing with family members who may isolate themselves; and coping with the medical consequences of the disease.

ADOLESCENTS. In IPT with adolescents, the therapist addresses such common developmental issues as separation from parents; the client's authority in relationship to parents; the development of new interpersonal relationships; first experiences of the death of a relative or friend; peer pressure; and single-parent families. Adolescents are seen weekly for 12 weeks with once-weekly additional phone contact between therapist and client for the first four weeks of treatment. The parents are interviewed in the initial session to get a comprehensive history of the adolescent's symptoms, and to educate the parents as well as the young person about depression and possible treatments, including a discussion of the need for medication. The therapist refrains from giving advice when working with adolescents, and will primarily use supportive listening, while assessing the client for evidence of suicidal thoughts or problems with school attendance. So far, research does not support the efficacy of antidepressant medication in treating adolescents, though most clinicians will give some younger clients a trial of medication if it appears to offer relief.

CLIENTS WITH SUBSTANCE ABUSE DISORDERS. While IPT has not yet demonstrated its efficacy in the field of substance abuse recovery, a version of IPT has been developed for use with substance abusers. The two goals are to help the client stop or cut down on drug use; and to help the client develop better strategies for dealing with the social and interpersonal consequences of drug use. To meet these goals, the client must accept the need to stop; take steps to manage impulsiveness; and recognize the social contexts of drug purchase and use. Relapse is viewed as the rule rather than the exception in treating substance abuse disorders, and the therapist avoids treating the client in a punitive or disapproving manner when it occurs. Instead, the therapist reminds the client of the fact that staying away from drugs is the client's decision.

CLIENTS WITH EATING DISORDERS. IPT has been extended to the treatment of eating disorders. The IPT therapist does not focus directly on the symptoms of the disorder, but rather, allows for identification of problem areas that have contributed to the emergence of the disorder over time. IPT appears to be useful in treating clients with bulimia whose symptoms are maintained by interpersonal issues, including social anxiety; sensitivity to conflict and rejection; and difficulty managing negative emotions. IPT is helpful in bringing the problems underlying the bingeing and purging to the surface, such as conflict avoidance; difficulties with role expectations; confusion regarding needs for closeness and distance; and deficiencies in solving social problems. IPT also helps people with bulimia to regulate the emotional states that maintain the bulimic behavior.

Anorexia nervosa also appears to be responsive to treatment with IPT. Research indicates that there is a connection between interpersonal and family dysfunction and the development of anorexia nervosa. Therapists disagree as to whether interpersonal dysfunction causes or is caused by anorexia. IPT has been helpful because it is not concerned with the origin but rather seeks to improve the client's interpersonal functioning and thereby decreasing symptoms. IPT's four categories of grief, interpersonal disputes, interpersonal deficits, and role transitions correspond to the core issues of clients with anorexia. Social phobia is another disorder that responds well to IPT therapy.

Aftercare

Interpersonal therapy as a maintenance approach (IPT-M) could be viewed as aftercare for clients suffering from depression. It is designed as a preventive measure by focusing on the period after the acute depression has passed. Typically, once the client is in remission and is symptom-free, he or she takes on more responsibilities and has increased social contact. These changes can lead to increased stress and greater vulnerability to another episode of depression. IPT-M enables clients to reduce the stresses associated with remission and thereby lower the risk of recurrence. The goal of maintenance therapy is to keep the client at his or her current level of functioning. Research has shown that for clients with a history of recurrent depression, total prevention is unlikely, but that maintenance therapy may delay a recurrence.

In general, long-term maintenance psychotherapy by itself is not recommended unless there are such reasons as pregnancy or severe side effects that prevent the client from being treated with medication. IPT-M does, however, seem to be particularly helpful with certain groups of patients, either alone or in combination with medication. Women appear to benefit, due to the importance of social environment and social relations in female gender roles; the effects of the menstrual cycle on symptoms; and complications related to victimization by rape, incest, or battering. IPT is also useful for elderly clients who can't take antidepressants due to intolerable side effects or such medical conditions as autoimmune disorders, cardiovascular disorders, diabetes, or other general medical conditions.

Normal results

The expected outcomes of interpersonal therapy are a reduction or the elimination of symptoms and improved interpersonal functioning. There will also be a greater understanding of the presenting symptoms and ways to prevent their recurrence. For example, in the case of depression, a person will have been educated about the nature of depression; what it looks like for him or her; and the interpersonal triggers of a depressive episode. A person will also leave therapy with strategies for minimizing triggers and for resolving future depressive episodes more effectively. While interpersonal therapy focuses on the present, it can also improve the client's future through increased awareness of preventive measures and strengthened coping skills.

Abnormal results

Research has shown that IPT requires clients' commitment to therapy prior to starting the treatment. If clients are resistant to an educational approach, the results of IPT are generally poor. It has been found that when people do not accept IPT's methods and approach at the outset, they are unlikely to be convinced over the course of therapy and they receive little benefit from treatment. IPT clients appear to do better in therapy if they have confidence in their therapist; therefore, if the initial fit between therapist and client is not good, therapy will often be unsuccessful. A client should listen to his or her instincts early in treatment, and either seek out another interpersonal therapist or find a therapist who uses a different approach— such as cognitive-behavioral therapy , which was also developed specifically for the treatment of depression.

See also Bulimia nervosa; Gender issues in mental health; Grief; Major depressive disorder

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Klerman, Gerald L., and others. Interpersonal Psychotherapy of Depression. New York: Basic Books, Inc., 1984.

Klerman, Gerald L., M.D., and Myrna M. Weissman, Ph.D., eds. New Applications of Interpersonal Psychotherapy. Washington, DC: American Psychiatric Press, Inc., 1993.

Mufson, Laura, Ph.D. Interpersonal Psychotherapy for Depressed Adolescents. New York: Guilford Press, 1993.

PERIODICALS

Apple, Robin F. "Interpersonal Therapy for Bulimia Nervosa." JCLP/In Session: Psychotherapy in Practice 55, no. 6 (1999): 715-725.

Barkham, Michael, and Gillian E. Hardy. "Counselling and interpersonal therapies for depression: towards securing an evidence-base." British Medical Bulletin 57 (2001): 115-132.

Frank, Ellen, Ph.D., and Michael E. Thase, M.D. "Natural History and Preventative Treatment of Recurrent Mood Disorders." Annual Reviews Medicine 50 (1999): 453-468.

House, Allan, D. M. "Brief psychodynamic interpersonal therapy after deliberate self-poisoning reduced suicidal ideation and deliberate self-harm." ACP Journal Club 136 (January/February 2002): 27.

McIntosh, Virginia V. "Interpersonal Psychotherapy for Anorexia Nervosa." International Journal of Eating Disorders 27 (March 2000): 125-139.

Mufson, Laura, Ph.D., and others. "Efficacy of Interpersonal Psychotherapy for Depressed Adolescents." Archives of General Psychiatry 56, no. 6 (June 1999): 573-579.

Weissman, Myrna M., Ph.D., and John C. Markowitz, M.D. "Interpersonal Psychotherapy: Current Status." Archives of General Psychiatry 51, no. 8 (August 1994): 599-606.

ORGANIZATIONS

International Society for Interpersonal Psychotherapy. c/o Myrna M. Weissman, Columbia University, 1051 Riverside Drive, Unit 24, New York, NY 10032. <http://interpersonalpsychotherapy.org>.

Holly Scherstuhl, M.Ed.

Family therapy

Definition

Family therapy is a type of psychotherapy that involves all members of a nuclear family or stepfamily and, in some cases, members of the extended family (e.g., grandparents). A therapist or team of therapists conducts multiple sessions to help families deal with important issues that may interfere with the functioning of the family and the home environment.

Purpose

The goal of family therapy is to help family members improve communication, solve family problems, understand and handle special family situations (for example, death, serious physical or mental illness, or child and adolescent issues), and create a better functioning home environment. For families with one member who has a serious physical or mental illness, family therapy can educate families about the illness and work out problems associated with care of the family member. For children and adolescents, family therapy most often is used when the child or adolescent has a personality, anxiety , or mood disorder that impairs their family and social functioning, and when a stepfamily is formed or begins having difficulties adjusting to the new family life. Families with members from a mixture of racial, cultural, and religious backgrounds, as well as families made up of same-sex couples who are raising children, may also benefit from family therapy.

Description

Family therapy is generally conducted by a therapist or team of therapists who are trained and experienced in family and group therapy techniques. Therapists may be psychologists, psychiatrists, social workers, or counselors. Family therapy involves multiple therapy sessions, usually lasting at least one hour each, conducted at regular intervals (for example, once weekly) for several months. Typically, family therapy is initiated to address a specific problem, such as an adolescent with a psychological disorder or adjustment to a death in the family. However, frequently, therapy sessions reveal additional problems in the family, such as communication issues. In a therapy session, therapists seek to analyze the process of family interaction and communication as a whole and do not take sides with specific family members. Therapists who work as a team can model new behaviors for the family through their interactions with each other during a session.

Family therapy is based on family systems theory, in which the family is viewed as a living organism rather than just the sum of its individual members. Family therapy uses systems theory to evaluate family members in terms of their position or role within the system as a whole. Problems are treated by changing the way the system works rather than trying to fix a specific member. Family systems theory is based on several major concepts.

Concepts in family therapy

the identified patient The identified patient (IP) is the family member with the symptom that has brought the family into treatment. Children and adolescents are frequently the IP in family therapy. The concept of the IP is used by family therapists to keep the family from scapegoating the IP or using him or her as a way of avoiding problems in the rest of the system.

homeostasis (balance) Homeostasis means that the family system seeks to maintain its customary organization and functioning over time, and it tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change.

the extended family field The extended family field includes the immediate family and the network of grandparents and other relatives of the family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviors, and other issues. Children and adolescents often benefit from family therapy that includes the extended family.

differentiation Differentiation refers to the ability of each family member to maintain his or her own sense of self, while remaining emotionally connected to the family. One mark of a healthy family is its capacity to allow members to differentiate, while family members still feel that they are members in good standing of the family.

triangular relationships Family systems theory maintains that emotional relationships in families are usually triangular. Whenever two members in the family system have problems with each other, they will "triangle in" a third member as a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that maintains family homeostasis. Common family triangles include a child and his or her parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.

In the early 2000s, a new systems theory, multisystemic therapy (MST), has been applied to family therapy and is practiced most often in a home-based setting for families of children and adolescents with serious emotional disturbances. MST is frequently referred to as a "family-ecological systems approach" because it views the family's ecology, consisting of the various systems with which the family and child interact (for example, home, school, and community). Several clinical studies have shown that MST has improved family relations, decreased adolescent psychiatric symptoms and substance use, increased school attendance, and decreased re-arrest rates for adolescents in trouble with the law. In addition, MST can reduce out-of-home placement of disturbed adolescents.

Preparation

In some instances the family may have been referred to a specialist in family therapy by their pediatrician or other primary care provider. It is estimated that as many as 50 percent of office visits to pediatricians have to do with developmental problems in children that are affecting their families. Some family doctors use symptom checklists or psychological screeners to assess a family's need for therapy. For children and adolescents with a diagnosed psychological disorder, family therapy may be added to individual therapy if family issues are identified as contributing factors during individual therapy.

Family therapists may be either psychiatrists, clinical psychologists, or other professionals certified by a specialty board in marriage and family therapy. They usually evaluate a family for treatment by scheduling a series of interviews with the members of the immediate family, including young children, and significant or symptomatic members of the extended family. This process allows the therapist(s) to find out how each member of the family sees the problem, as well as to form first impressions of the family's functioning. Family therapists typically look for the level and types of emotions expressed, patterns of dominance and submission, the roles played by family members, communication styles, and the locations of emotional triangles. They also note whether these patterns are rigid or relatively flexible.

Preparation also usually includes drawing a genogram, which is a diagram that depicts significant persons and events in the family's history. Genograms include annotations about the medical history and major personality traits of each member. Genograms help uncover intergenerational patterns of behavior, marriage choices, family alliances and conflicts, the existence of family secrets, and other information that sheds light on the family's present situation.

Precautions

Individual therapy for one or more family members may be recommended to avoid volatile interaction during a family therapy session. Some families are not considered suitable candidates for family therapy. They include:

• families in which one, or both, of the parents is psychotic or has been diagnosed with antisocial or paranoid personality disorder
• families whose cultural or religious values are opposed to, or suspicious of, psychotherapy
• families with members who cannot participate in treatment sessions because of physical illness or similar limitations
• families with members with very rigid personality structures (Here, members might be at risk for an emotional or psychological crisis.)
• families whose members cannot or will not be able to meet regularly for treatment

Risks

The chief risk in family therapy is the possible unsettling of rigid personality defenses in individuals or relationships that had been fragile before the beginning of therapy. Intensive family therapy may also be difficult for family members with diagnosed psychological disorders. Family therapy may be especially difficult and stressful for children and adolescents who may not fully understand interactions that occur during family therapy. Adding individual therapy to family therapy for children and adolescents with the same therapist (if appropriate) or a therapist who is aware of the family therapy can be helpful.

Normal results

Normal results vary, but in good circumstances, they include greater insight, increased differentiation of individual family members, improved communication within the family, loosening of previously automatic behavior patterns, and resolution of the problem that led the family to seek treatment.

Parental concerns

Stepfamilies , which are increasing in prevalence, are excellent candidates for family therapy. Children and adolescents in stepfamilies often have difficulties adjusting, and participating in family therapy can be beneficial. Stepfamilies, increasingly referred to as "blended families," experience unique pressures within each new family unit. Stepfamily researchers, family therapists, and the Stepfamily Association of America (SAA) view the term as inaccurate because it seems to suggest that members of a stepfamily blend into an entirely new family unit, losing their individuality and attachment to other outside family members. Because other family types (biological, single-parent, foster, adoptive) are defined by the parent-child relationship, the SAA believes that the term "stepfamily" more accurately reflects that relationship and is consistent with other family definitions. Viewing the stepfamily as a blended family can lead to unrealistic expectations, confused and conflicted children, difficult adjustment, and in many cases, failure of the marriage and family. Family therapy can help family members deal with these issues.

Children and adolescents and, in some cases even the parents, may be reluctant to participate in family therapy. Home-based family therapy has in the early 2000s become available as an option for families with severely disturbed adolescents and family members reluctant to see a therapist. In home-based therapy, a therapist or team of therapists comes directly to the family's home and conducts therapy sessions there.

KEY TERMS

Blended family —A family formed by the remarriage of a divorced or widowed parent. It includes the new husband and wife, plus some or all of their children from previous marriages.

Differentiation —The ability to retain one's identity within a family system while maintaining emotional connections with the other members.

Extended family field —A person's family of origin plus grandparents, in-laws, and other relatives.

Family systems theory —An approach to treatment that emphasizes the interdependency of family members rather than focusing on individuals in isolation from the family. This theory underlies the most influential forms of contemporary family therapy.

Genogram —A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the family members understand their problem(s).

Homeostasis —The balanced internal environment of the body and the automatic tendency of the body to maintain this internal "steady state." Also refers to the tendency of a family system to maintain internal stability and to resist change.

Identified patient (IP) —The family member in whom the family's symptom has emerged or is most obvious.

Nuclear family —The basic family unit, consisting of a father, a mother, and their biological children.

Stepfamily —A family formed by the marriage or long-term cohabitation of two individuals, where one or both have at least one child from a previous relationship living part-time or full-time in the household. The individual who is not the biological parent of the child or children is referred to as the stepparent.

Triangling —A process in which two family members lower the tension level between them by drawing in a third member.

Resources

BOOKS

Barnes, Gill Gorell. Family Therapy in Changing Times. Gordonville, VA: Palgrave Macmillan, 2004.

Carlson, Jon, et al. Family Therapy Techniques: Integrating and Tailoring Treatment. Florence, KY: Brunner-Routledge, 2005.

Landau, Elaine. Family Therapy. Danbury, CT: Scholastic Library Publishing, 2004.

Sells, Scott P. Treating the Tough Adolescent: A Family-Based, Step-by-Step Guide. New York: Guilford Publications, 2004.

PERIODICALS

Cortes, Linda. "Home-Based Family Therapy: A Misunderstanding of the Role and a New Challenge for Therapists." The Family Journal: Counseling and Therapy for Couples and Families 12 (April 2004): 184–88.

Heater, Mary Lou. "Ethnocultural Considerations in Family Therapy." Journal of the American Psychiatric Nurses Association 9 (April 2003): 46–54.

Hutton, Deborah. "Filial Therapy: Shifting the Balance." Clinical Child Psychology and Psychiatry 9 (April 2004): 261–70.

Sheidow, Ashli J., and Mark S. Woodford. "Multisystemic Therapy: An Empirically Supported, Home-Based Family Therapy Approach." The Family Journal: Counseling and Therapy for Couples and Families 11 (July 2003): 257–63.

ORGANIZATIONS

American Association for Marriage and Family Therapy. 112 South Alfred St., Alexandria, VA 22314–3061. Web site: <www.aamft.org/index_nm.asp>.

International Family Therapy Association. Web site: <www.ifta-familytherapy.org/about.htm>.

Stepfamily Association of America. Web site: <www.saafamilies.org>.

Stepfamily Foundation. Web site: <www.stepfamily.org>.

Jennifer E. Sisk, M.A.

Family Therapy

Definition

Purpose

Precautions

Description

Preparation

Risks

Normal results

Resources

Definition

Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family. The purpose of family therapy is to improve relationships between family members and improve behavior patterns of the family as a whole or subgroups within the family. Family therapy may be conducted by a pair of therapists—often a man and a woman—to treat gender-related issues or serve as role models for family members. Although some types of family therapy are based on behavioral or psychodynamic principles, the most widespread form is based on family systems theory, an approach that regards the entire family as the unit of treatment, and emphasizes such factors as relationships and communication patterns rather than traits or symptoms in individual members.

History

Family therapy is a relatively recent development in psychotherapy. It began shortly after World War II, when doctors who were treating patients with schizophrenia noticed that the patients’ families communicated in disturbed ways. The doctors also found that patients’ symptoms rose or fell according to the level of tension between their parents. These observations led to considering a family as an organism (or system) with its own internal rules, patterns of functioning, and tendency to resist change. When the therapists began to treat the families as whole units instead of focusing solely on the hospitalized member, they found that in many cases the family member with schizophrenia improved. (This does not mean that schizophrenia is caused by family problems, although they may aggravate its symptoms.) This approach was then applied to families with problems other than schizophrenia. Family therapy is becoming an increasingly common form of treatment as changes in American society are reflected in family structures; it is also helpful when a child or other family member develops a serious physical illness.

Purpose

Family therapy is often recommended when:

• a family member has schizophrenia or another severe psychosis; the goal in these cases is to help other family members understand the disorder and adjust to the psychological changes that may be occurring in the patient.
• problems cross generational boundaries, such as when parents share a home with grandparents, or children are being raised by grandparents.
• families deviate from social norms (unmarried parents, gay couples rearing children, etc.). These families may or may not have internal problems, but could be troubled by societal attitudes.
• members come from mixed racial, cultural, or religious backgrounds.
• one member is being scapegoated, or their treatment in individual therapy is being undermined.

VIRGINIA SATIR (1916-1988)

For the techniques she created to treat troubled families, Virginia Satir was known worldwide as a pioneer in the development of family therapy. After earning a bachelor’s degree from Wisconsin State University in 1936, Satir taught for six years at schools in Wisconsin, Michigan, and Louisiana. She became interested in the relationship between dysfunctional individuals and their families, and, deciding to specialize in family analysis, went back to school to earn a master’s degree in 1948 at the University of Chicago. Satir subsequently worked as a therapist and social worker at mental hospitals and public welfare programs and conducted more than four hundred workshops for the government, hospitals, and universities throughout the United States. In addition, Satir helped found the Mental Research Institute in 1959 and, twenty years later, established the International Human Learning Resource Network. A leader in developing the concept of self-worth, Satir conveyed her psychological philosophies in such books as Conjoint Family Therapy: A Guide to Theory and Technique, Peoplemaking, Self Esteem, Helping Families to Change, and Making Contact.

• the identified patient’s problems seem inextricably tied to problems with other family members.
• a blended (i.e. step-) family is having adjustment difficulties.

Precautions

Families not considered suitable candidates for family therapy include those in which:

• one or both parents is psychotic or has been diagnosed with antisocial or paranoid personality disorder.
• cultural or religious values are opposed to, or suspicious of, psychotherapy.
• family members cannot participate in treatment sessions because of illness or other physical limitations.
• individuals have very rigid personality structures and might be at risk for an emotional or psychological crisis.
• members cannot or will not be able to meet regularly for treatment.
• the family is unstable or on the verge of breakup.

Intensive family therapy may be difficult for family members with psychoses.

Description

Family therapy tends to be short-term, usually several months in length, and is aimed at resolving specific problems such as eating disorders, difficulties with school, or adjustments to bereavement or geographical relocation. It is not normally used for long-term or intensive restructuring of families with severe dysfunctions.

In therapy sessions, all members of the family and both therapists (if there is more than one) are present. The therapists try to analyze communication and interaction between all members of the family; they do not side with specific members, although they may make occasional comments to help members become more conscious of patterns previously taken for granted. Therapists who work as a team also model new behaviors through their interactions with each other.

Family therapy is based on systems theory, which maintains that the family is a living organism that is more than the sum of its individual members and evaluates family members in terms of their position or role within the system. Problems are treated by changing the way the system works rather than trying to “fix” a specific member.

Family systems theory is based on several major concepts:

• the identified patient: The identified patient (IP) is the family member with the symptom that has brought the family into treatment. The concept of the IP is used to keep the family from scapegoating the IPs or using them as a way of avoiding problems in the rest of the system.
• homeostasis: This concept presumes that the family system tends to resist change and seeks to maintain its customary organization and functioning over time. The family therapist can use homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change.
• the extended family field: The extended family field is the nuclear family plus the network of grandparents and other members of the extended family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviors, and other issues.
• differentiation: Differentiation refers to each family member’s ability to maintain a sense of self while remaining emotionally connected to the family; this is the mark of a healthy family.
• triangular relationship: Family systems theory maintains that emotional difficulties in families are usually triangular—whenever any two people have problems with each other, they will “triangle in” a third member to stabilize their own relationship.

These triangles usually interlock in a way that maintains homeostasis. Common family triangles include a child and the parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.

Preparation

Families are often referred to a specialist in family therapy by a pediatrician or other primary care provider. (Some estimates suggest that as many as 50% of pediatric office visits concern developmental problems in children that are affecting their families.) Physicians may use symptom checklists or psychological screen-ers to assess a family’s need for therapy.

Family therapists can be psychiatrists, clinical psychologists, or other professionals certified by a specialty board in marriage and family therapy. They will usually evaluate a family for treatment by scheduling a series of interviews with members of the immediate family, including young children, as well as significant or symptomatic members of the extended family. This allows the therapists to learn how each family member sees the problem and provides a first impression of the family’s functioning. Therapists typically evaluate the level and types of emotions expressed, patterns of dominance and submission, roles played by family members, communication styles, and the existence of emotional triangles. They also note whether these patterns are rigid or relatively flexible.

Preparation also usually includes creating a geno-gram, a diagram that depicts significant people and events in the family’s history. Genograms include annotations about the medical history and major personality traits of each member and help uncover inter-generational patterns of behavior, marriage choices, family alliances and conflicts, the existence of family secrets, and other information that sheds light on the family’s present situation.

Risks

There are no major risks involved in receiving family therapy, especially if family members seek therapy with honesty, openness, and a willingness to change. Changes that result from the therapy may be seen as “risks”—the possible unsettling of rigid personality defenses in individuals, or the unsettling of couple relationships that had been fragile before the beginning of therapy, for example.

Normal results

The goal of therapy is the identification and resolution of the problem that is causing the family’s unhealthy interactions. Results vary, but in good circumstances

KEY TERMS

Blended family —A family formed by the remarriage of a divorced or widowed parent. It includes a new husband and wife, plus some or all of their children from previous marriages.

Differentiation —The ability to retain one’s identity within a family system while maintaining emotional connections with the other members.

Extended family field —A person’s family of origin plus grandparents, in-laws, and other relatives.

Family systems theory —An approach to treatment that emphasizes the interdependency of family members rather than focusing on individuals in isolation from the family. This theory underlies the most influential forms of contemporary family therapy.

Genogram —A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the members understand their problems.

Homeostasis —The tendency of a family system to maintain internal stability and resist change.

Identified patient (IP) —The family member whose symptom has emerged or is most obvious.

Nuclear family —The basic family unit, consisting of father, mother, and their biological children.

Scapegoating —The emergence of behavioral problems in one family member, usually the identified patient, who is often punished for problems within the entire family.

Triangling —A process in which two family members diminish the tension between them by drawing in a third member.

they include greater insight, increased differentiation of individual family members, improved communication within the family, and loosening of previously automatic behavior patterns.

Resources

BOOKS

Gladding, Samuel T. Family Therapy: History, Theory, and Practice. 4th ed. Upper Saddle River, NJ: Prentice Hall, 2006.

Goldenberg, Herbert, and Irene Goldenberg. Family Therapy: An Overview. Belmont, CA: Brooks/Cole, 2007.

McGoldrick, Monica, Joe Giordano, and Nydia Garcia-Preto, eds. Ethnicity and Family Therapy. 3rd ed. New York: The Guilford Press, 2005.

Minuchin, Salvador, and H. Charles Fishman. Family Therapy Techniques. Cambridge, MA: Harvard University Press, 2004.

Nichols, Michael P., and Richard C. Schwartz. Family Therapy: Concepts and Methods. 7th ed. Boston: Allyn & Bacon, 2005.

Nichols, Michael P., and Richard C. Schwartz Essentials of Family Therapy. 3rd ed. Boston: Allyn & Bacon, 2006.

VandenBos, Gary R., ed. APA Dictionary of Psychology. Washington, D.C.: American Psychological Association, 2006.

PERIODICALS

Betz, Gabrielle, and Jill M. Thorngren. “Ambiguous Loss and the Family Grieving Process.” Family Journal: Counseling and Therapy for Couples and Families 14.4 (Oct. 2006): 359–65.

Hogue, Aaron, and others. “Treatment Techniques and Outcomes in Multidimensional Family Therapy for Adolescent Behavior Problems.” Journal of Family Psychology 20.4 (Dec. 2006): 535–43.

Hunter, Sally V. “Understanding the Complexity of Child Sexual Abuse: A Review of the Literature with Implications for Family Counseling.” Family Journal: Counseling and Therapy for Couples and Families 14.4 (Oct. 2006): 349–58.

Lemmens, Gilbert, and others. “Family Discussion Group Therapy for Major Depression: A Brief Systemic Multi-Family Group Intervention for Hospitalized Patients and Their Family Members.” Journal of Family Therapy 29.1 (Feb. 2007): 49–68.

Lock, James, and others. “Is Family Therapy Useful for Treating Children With Anorexia Nervosa? Results of a Case Series.” Journal of the American Academy of Child & Adolescent Psychiatry 45.11 (Nov. 2006): 1323–28.

Miklowitz, David J., and Dawn O. Taylor. “Family-Focused Treatment of the Suicidal Bipolar Patient.” Bipolar Disorders 8.5 part 2 (Oct. 2006): 640–51.

St. George, Sally, and Dan Wulff. “A Postmodern Approach to Teaching Family Therapy as Community Practice.” Journal of Systemic Therapies 25.4 (Winter 2006): 73–83.

Schweitzer, Jochen, and others. “Training Psychiatric Teams to Do Family Systems Acute Psychiatry.” Journal of Family Therapy 29.1 (Feb. 2007): 3–20.

Trepal, Heather C., and Kelly L. Wester. “Self-Injury and Postvention: Responding to the Family in Crisis.” Family Journal: Counseling and Therapy for Couples and Families 14.4 (Oct. 2006): 342–48.

Rebecca J. Frey, PhD

Ruth A. Wienclaw, PhD

Family Therapy

Definition

Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family. It may be conducted by a pair or team of therapists. In many cases the team consists of a man and a woman in order to treat gender-related issues or serve as role models for family members. Although some forms of family therapy are based on behavioral or psychodynamic principles, the most widespread form is based on family systems theory. This approach regards the family, as a whole, as the unit of treatment, and emphasizes such factors as relationships and communication patterns rather than traits or symptoms in individual members.

Family therapy is a relatively recent development in psychotherapy. It began shortly after World War II, when doctors, who were treating schizophrenic patients, noticed that the patients' families communicated in disturbed ways. The doctors also found that the patients' symptoms rose or fell according to the level of tension between their parents. These observations led to considering a family as an organism or system with its own internal rules, patterns of functioning, and tendency to resist change. The therapists started to treat the families of schizophrenic patients as whole units rather than focusing on the hospitalized member. They found that in many cases the family member with schizophrenia improved when the "patient" was the family system. (This should not be misunderstood to mean that schizophrenia is caused by family problems, although family problems may worsen the condition.) This approach of involving the entire family in the treatment plan and therapy was then applied to families with problems other than the presence of schizophrenia.

Family therapy is becoming an increasingly common form of treatment as changes in American society are reflected in family structures. It has led to two further developments: couples therapy, which treats relationship problems between marriage partners or gay couples; and the extension of family therapy to religious communities or other groups that resemble families.

Purpose

Family therapy is often recommended in the following situations:

• Treatment of a family member with schizophrenia or multiple personality disorder (MPD). Family therapy helps other family members understand their relative's disorder and adjust to the psychological changes that may be occurring in the relative.
• Families with problems across generational boundaries. These would include problems caused by parents sharing housing with grandparents, or children being reared by grandparents.
• Families that deviate from social norms (commonlaw relationships, gay couples rearing children, etc.). These families may not have internal problems but may be troubled by outsiders' judgmental attitudes.
• Families with members from a mixture of racial, cultural, or religious backgrounds.
• Families who are scapegoating a member or undermining the treatment of a member in individual therapy.
• Families where the identified patient's problems seem inextricably tied to problems with other family members.
• Blended families with adjustment difficulties.

Most family therapists presuppose an average level of intelligence and education on the part of adult members of the family.

Precautions

Some families are not considered suitable candi- dates for family therapy. They include:

• families in which one, or both, of the parents is psychotic or has been diagnosed with antisocial or paranoid personality disorder,
• families whose cultural or religious values are opposed to, or suspicious of, psychotherapy,
• families with members who cannot participate in treatment sessions because of physical illness or similar limitations,
• families with members with very rigid personality structures. (Here, members might be at risk for an emotional or psychological crisis),
• families whose members cannot or will not be able to meet regularly for treatment,
• families that are unstable or on the verge of breakup.

Description

Family therapy tends to be short-term treatment, usually several months in length, with a focus on resolving specific problems such as eating disorders, difficulties with school, or adjustments to bereavement or geographical relocation. It is not normally used for long-term or intensive restructuring of severely dysfunctional families.

In family therapy sessions, all members of the family and both therapists (if there is more than one) are present at most sessions. The therapists seek to analyze the process of family interaction and communication as a whole; they do not take sides with specific members. They may make occasional comments or remarks intended to help family members become more conscious of patterns or structures that had been previously taken for granted. Family therapists, who work as a team, also model new behaviors for the family through their interactions with each other during sessions.

Family therapy is based on family systems theory, which understands the family to be a living organism that is more than the sum of its individual members. Family therapy uses "systems" theory to evaluate family members in terms of their position or role within the system as a whole. Problems are treated by changing the way the system works rather than trying to "fix" a specific member. Family systems theory is based on several major concepts:

The identified patient

The identified patient (IP) is the family member with the symptom that has brought the family into treatment. The concept of the IP is used by family therapists to keep the family from scapegoating the IP or using him or her as a way of avoiding problems in the rest of the system.

Homeostasis (balance)

The concept of homeostasis means that the family system seeks to maintain its customary organization and functioning over time. It tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change.

The extended family field

The extended family field refers to the nuclear family, plus the network of grandparents and other members of the extended family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviors, and other issues.

Differentiation

Differentiation refers to the ability of each family member to maintain his or her own sense of self, while remaining emotionally connected to the family. One mark of a healthy family is its capacity to allow members to differentiate, while family members still feel that they are "members in good standing" of the family.

Triangular relationships

Family systems theory maintains that emotional relationships in families are usually triangular. Whenever any two persons in the family system have problems with each other, they will "triangle in" a third member as a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that maintains family homeostasis. Common family triangles include a child and its parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.

Preparation

In some instances the family may have been referred to a specialist in family therapy by their pediatrician or other primary care provider. It is estimated that as many as 50% of office visits to pediatricians have to do with developmental problems in children that are affecting their families. Some family doctors use symptom checklists or psychological screeners to assess a family's need for therapy.

Family therapists may be either psychiatrists, clinical psychologists, or other professionals certified by a specialty board in marriage and family therapy. They will usually evaluate a family for treatment by scheduling a series of interviews with the members of the immediate family, including young children, and significant or symptomatic members of the extended family. This process allows the therapist(s) to find out how each member of the family sees the problem, as well as to form first impressions of the family's functioning. Family therapists typically look for the level and types of emotions expressed, patterns of dominance and submission, the roles played by family members, communication styles, and the locations of emotional triangles. They will also note whether these patterns are rigid or relatively flexible.

Preparation also usually includes drawing a genogram, which is a diagram that depicts significant persons and events in the family's history. Genograms also include annotations about the medical history and major personality traits of each member. Genograms help in uncovering intergenerational patterns of behavior, marriage choices, family alliances and conflicts, the existence of family secrets, and other information that sheds light on the family's present situation.

KEY TERMS

Blended family— A family formed by the remarriage of a divorced or widowed parent. It includes the new husband and wife, plus some or all of their children from previous marriages.

Differentiation— The ability to retain one's identity within a family system while maintaining emotional connections with the other members.

Extended family field— A person's family of origin plus grandparents, in-laws, and other relatives.

Family systems theory— An approach to treatment that emphasizes the interdependency of family members rather than focusing on individuals in isolation from the family. This theory underlies the most influential forms of contemporary family therapy.

Genogram— A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the members understand their problem(s).

Homeostasis— The tendency of a family system to maintain internal stability and resist change.

Identified patient (IP)— The family member in whom the family's symptom has emerged or is most obvious.

Nuclear family— The basic family unit, consisting of father, mother, and their biological children.

Triangling— A process in which two family members lower the tension level between them by drawing in a third member.

Risks

The chief risk in family therapy is the possible unsettling of rigid personality defenses in individuals, or couple relationships that had been fragile before the beginning of therapy. Intensive family therapy may also be difficult for psychotic family members.

Normal results

Normal results vary, but in good circumstances, they include greater insight, increased differentiation of individual family members, improved communication within the family, loosening of previously automatic behavior patterns, and resolution of the problem that led the family to seek treatment.

Resources

BOOKS

Clark, R. Barkley. "Psychosocial Aspects of Pediatrics & Psychiatric Disorders: Psychosocial Assessment of Children & Families." In Current Pediatric Diagnosis & Treatment, edited by William W. Hay Jr., et al. Stamford: Appleton & Lange, 1997.