An Overview about Family Therapy

**3**

**Chapter 1**

**Abstract**

effective therapy.

**1. Introduction**

systemic therapy, family therapy

A Chronological Map of Common

Meta-analysis research supports the notion that common factors are at work across theoretically different therapies. However, some advocates of empirically supported treatments (ESTs) criticize that there is no common factor chronological map to guide clinicians across different stages of therapy (initial, intermediate, termination). In this chapter, supported by recent research, we propose a preliminary chronological map which has the potential to guide clinicians as they use common factors across all three stages of couple and family therapy. The common factors approach is an overarching therapeutic model within which the therapist can determine and use well-timed common mechanisms of change to support therapy's success. This is consistent with the AAMFT Core Competencies to provide safe and

Outcome research has supported the therapy effectiveness in psychotherapy and Marriage and Family Therapy (MFT) fields [1]. The findings, over decades of comparative studies, indicate therapy is effective. It can be as effective as medical treatment, and its outcome can last longer than medical treatment [2, 3]. However, the therapy field still deals with controversial debates regarding how therapy

In reaction to Hans Eysenck's [6] claim that psychotherapy is ineffective, a series of outcome research studies were conducted that itself caused the emergence of competitive treatment models. Such a trend led in the movement of Empirically Supported Treatments (ESTs) to find the most effective treatments for specific problems [3, 7, 8]. That is, the advocates of ESTs assumed their model-specific factors/techniques were the mechanisms responsible for therapy effectiveness [9]. Therefore, these researchers support outcome research and more controlled comparative studies to establish a specific treatment manual for each specific clinical problem [10]. On the other hand, the advocates of the common factors (CFs) approach believe that shared factors/change mechanisms are responsible for therapeutic outcome across all successful treatment models [3, 8]. They assume that there is not one significant model that achieves higher efficacy than others. For a

Factors across Three Stages of

Marriage and Family Therapy

*Hassan Karimi, Fred Piercy and Jyoti Savla*

**Keywords:** common factors, chronological map, process-research,

provides change and thorough what mechanisms? [4, 5].

#### **Chapter 1**

## A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy

*Hassan Karimi, Fred Piercy and Jyoti Savla*

#### **Abstract**

Meta-analysis research supports the notion that common factors are at work across theoretically different therapies. However, some advocates of empirically supported treatments (ESTs) criticize that there is no common factor chronological map to guide clinicians across different stages of therapy (initial, intermediate, termination). In this chapter, supported by recent research, we propose a preliminary chronological map which has the potential to guide clinicians as they use common factors across all three stages of couple and family therapy. The common factors approach is an overarching therapeutic model within which the therapist can determine and use well-timed common mechanisms of change to support therapy's success. This is consistent with the AAMFT Core Competencies to provide safe and effective therapy.

**Keywords:** common factors, chronological map, process-research, systemic therapy, family therapy

#### **1. Introduction**

Outcome research has supported the therapy effectiveness in psychotherapy and Marriage and Family Therapy (MFT) fields [1]. The findings, over decades of comparative studies, indicate therapy is effective. It can be as effective as medical treatment, and its outcome can last longer than medical treatment [2, 3]. However, the therapy field still deals with controversial debates regarding how therapy provides change and thorough what mechanisms? [4, 5].

In reaction to Hans Eysenck's [6] claim that psychotherapy is ineffective, a series of outcome research studies were conducted that itself caused the emergence of competitive treatment models. Such a trend led in the movement of Empirically Supported Treatments (ESTs) to find the most effective treatments for specific problems [3, 7, 8]. That is, the advocates of ESTs assumed their model-specific factors/techniques were the mechanisms responsible for therapy effectiveness [9]. Therefore, these researchers support outcome research and more controlled comparative studies to establish a specific treatment manual for each specific clinical problem [10]. On the other hand, the advocates of the common factors (CFs) approach believe that shared factors/change mechanisms are responsible for therapeutic outcome across all successful treatment models [3, 8]. They assume that there is not one significant model that achieves higher efficacy than others. For a

few decades, we have seen a loop of research between the two camps. The advocates of model specificity piled supportive findings for their models' efficacy, which provided more raw data for advocates of CFs to run meta-analysis that shows equal efficacy across different treatment models [3, 11]. Breaking such a loop toward a better understanding of therapeutic change mechanisms requires more process research and multiple research methods [4, 5, 11]. Process research, by focusing on specific "whats," "whys," "whens," and "hows," can contribute to more clinically relevant and theoretically integrative models.

In this chapter, we provide an overview of the common factors approach and its development. We also discuss the critiques that ESTs advocates posit on CFs approach. Then, we propose a chronological map of when certain common factors are most relevant, which is supported by our qualitative research, as well as other MFT literature. Finally, we discuss the research, clinical, and training implications of the chronological map.

#### **2. Development of common factors approach**

Rosenzweig [12] was the first to discuss common factors in the literature. He suggested therapy effectiveness is due to a therapeutic relationship and a treatment rationale that justifies therapeutic tasks. Frank's [13] work prepared the field to move toward integrative therapies. Frank proposed four key dimensions of healing process: (1) an emotionally charged confiding relationship, (2) a therapeutic context, (3) a credible rational that provides a convincing explanation for the client's problem and how to resolve it, and (4) a procedure or task that requires active participation of the client. Then, the research of Luborsky et al. [14] found equivalency of effectiveness across active treatments, which indicated three of every four clients improved, regardless of treatment type.

Lambert [15], based on a review of outcome studies, proposed a four-factors model of what factors contribute to effectiveness, with estimated percentages, including extra-therapeutic change factors 40%, common factors 30%, technique factors 15%, and expectancy factors 15%. Though these percentages were mostly interpreted or cited as factual, empirical evidence, a recent study by Karimi [16] indicates that the percentage of each CFs category can vary due to specific characteristics of therapist, client, problem, etc. That is, the CFs are not a set of static factors, but are dynamic and interactive factors. Another significant contribution by Lambert [15] is a developmental conceptualization of therapy as a process that contains three sequencing stages: support factors, learning factors, and action factors.

A few other insightful theories of integration [17–20] have been introduced in the field, which emphasized mostly common mechanisms/processes of change across treatment models. For example, Goldfried and Padawer [18] conceptualized therapy at three differentiated levels that include: *theories, strategies, and interventions*. At the highest level of abstraction, theories intend to explain human functioning and pathology. At the lowest level of abstraction, techniques which are linked to specific theories intend to generate change. And strategies are within the middle level of abstraction which can be activated by different techniques. It seems that experienced therapists consider these strategies or change processes as a heuristic guide in their practice [21]. For example, the therapists deliberately can choose from seemingly different techniques (e.g., cognitive restructuring, empty chair, family sculpting, paradoxical homework, etc.) when they target a particular change process (e.g., detriangling from parents), which meets the therapy goal (improvement of depression).

**5**

**2.1 Client factors**

**2.2 Therapist factors**

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

Though, the advocates of ESTs insist on manualizing specific protocols for specific problems/disorders [9]. The integrative and CFs scholars [11, 22] challenge the uniformity myths in ESTs, which assumes therapy is consistently applied across therapists and clients. In theory, the therapist may start with a specific model, but in actual practice, the therapist's behavior is mostly guided by the client's responses/

Sprenkle and Blow [11] proposed a moderate definition of CFs in the marriage and family therapy field; they consider CFs as the main mechanisms of change, though specific models play a role in therapeutic change too. In fact, they consider models as vehicles that delineate a temporal sequence indicating when each CFs should be punctuated during the therapy process. They proposed six categories of common factors: client, therapist, relationship, expectancy/hope, Non-specific mechanisms, unique MFT common factors. Since therapy inherently is a multilevel interactional process [21, 22], such a distinction between the components is more artificial than factual. For the purpose of this chapter, we use this moderate definition of common factors. However, we believe future research may well modify these common factors or introduce new items to improve the conceptualization of CFs.

Client factors include a set of characteristics (e.g., motivation, spirituality and religious faith, cognitive ability, self-agency, cooperation on therapeutic tasks, perseverance, expectations) that are potential resources that relate to clients' movement toward their therapy goal. Unfortunately, professional centrism caused the field to overlook the invaluable therapeutic potency of client factors [8, 26]. Clients usually edit and reconstruct therapeutic interventions and the therapist's style to individualize them to their values and goals. According to Miller and associates [27], "The research literature makes it clear that the client is actually the single most

Researchers proposed a set of characteristics for therapists (e.g., therapist positivity and friendliness, level of activity in the session, providing structure to face clients with cognitive, emotional, and behavioral experiences, therapist openness, therapist's ability to adapt to client's preferences, therapist's cultural sensitivity) that contribute in therapy outcome [3, 8]. Researchers using Randomized Clinical Trials (RCTs) studies usually try to control the therapist's variables. However, reanalysis of the most comprehensive evidence-based study on depression (American Psychological Association, Task Force, 1993) identified therapist effectiveness as the main treatment factor; while the treatment models, settings, and even the experience level of therapists were controlled [25]. Also, a meta-analysis of psychotherapy outcome studies [3] has found that clinicians' differences contributed more effect size (0.65) to outcome variance than the treatment models themselves (0.20). Therefore, the therapist's role in therapy outcome is sometimes referred to as a "neglected variable" [28]. Consequently, more research on therapist's competency

characteristics, so the process turns into a progressively individualized one [23, 24]. In addition, the most comprehensive evidence-based study to date (American Psychological Association Task Force, 1993) indicated that there were no differences among all forms of treatment (cognitive behavioral therapy, interpersonal therapy, medication with management, and placebo plus clinical management) on the client's level of depression, but there was a difference in the level of the therapeutic efficacy of the therapists; while the treatment models, the settings,

and even the therapist experience were controlled [25].

potent contributor to outcome in psychotherapy."

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

#### *A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

Though, the advocates of ESTs insist on manualizing specific protocols for specific problems/disorders [9]. The integrative and CFs scholars [11, 22] challenge the uniformity myths in ESTs, which assumes therapy is consistently applied across therapists and clients. In theory, the therapist may start with a specific model, but in actual practice, the therapist's behavior is mostly guided by the client's responses/ characteristics, so the process turns into a progressively individualized one [23, 24]. In addition, the most comprehensive evidence-based study to date (American Psychological Association Task Force, 1993) indicated that there were no differences among all forms of treatment (cognitive behavioral therapy, interpersonal therapy, medication with management, and placebo plus clinical management) on the client's level of depression, but there was a difference in the level of the therapeutic efficacy of the therapists; while the treatment models, the settings, and even the therapist experience were controlled [25].

Sprenkle and Blow [11] proposed a moderate definition of CFs in the marriage and family therapy field; they consider CFs as the main mechanisms of change, though specific models play a role in therapeutic change too. In fact, they consider models as vehicles that delineate a temporal sequence indicating when each CFs should be punctuated during the therapy process. They proposed six categories of common factors: client, therapist, relationship, expectancy/hope, Non-specific mechanisms, unique MFT common factors. Since therapy inherently is a multilevel interactional process [21, 22], such a distinction between the components is more artificial than factual. For the purpose of this chapter, we use this moderate definition of common factors. However, we believe future research may well modify these common factors or introduce new items to improve the conceptualization of CFs.

#### **2.1 Client factors**

*Family Therapy - New Intervention Programs and Researches*

relevant and theoretically integrative models.

**2. Development of common factors approach**

clients improved, regardless of treatment type.

of the chronological map.

few decades, we have seen a loop of research between the two camps. The advocates of model specificity piled supportive findings for their models' efficacy, which provided more raw data for advocates of CFs to run meta-analysis that shows equal efficacy across different treatment models [3, 11]. Breaking such a loop toward a better understanding of therapeutic change mechanisms requires more process research and multiple research methods [4, 5, 11]. Process research, by focusing on specific "whats," "whys," "whens," and "hows," can contribute to more clinically

In this chapter, we provide an overview of the common factors approach and its development. We also discuss the critiques that ESTs advocates posit on CFs approach. Then, we propose a chronological map of when certain common factors are most relevant, which is supported by our qualitative research, as well as other MFT literature. Finally, we discuss the research, clinical, and training implications

Rosenzweig [12] was the first to discuss common factors in the literature. He suggested therapy effectiveness is due to a therapeutic relationship and a treatment rationale that justifies therapeutic tasks. Frank's [13] work prepared the field to move toward integrative therapies. Frank proposed four key dimensions of healing process: (1) an emotionally charged confiding relationship, (2) a therapeutic context, (3) a credible rational that provides a convincing explanation for the client's problem and how to resolve it, and (4) a procedure or task that requires active participation of the client. Then, the research of Luborsky et al. [14] found equivalency of effectiveness across active treatments, which indicated three of every four

Lambert [15], based on a review of outcome studies, proposed a four-factors model of what factors contribute to effectiveness, with estimated percentages, including extra-therapeutic change factors 40%, common factors 30%, technique factors 15%, and expectancy factors 15%. Though these percentages were mostly interpreted or cited as factual, empirical evidence, a recent study by Karimi [16] indicates that the percentage of each CFs category can vary due to specific characteristics of therapist, client, problem, etc. That is, the CFs are not a set of static factors, but are dynamic and interactive factors. Another significant contribution by Lambert [15] is a developmental conceptualization of therapy as a process that contains three sequencing stages: support factors, learning factors, and action

A few other insightful theories of integration [17–20] have been introduced in the field, which emphasized mostly common mechanisms/processes of change across treatment models. For example, Goldfried and Padawer [18] conceptualized therapy at three differentiated levels that include: *theories, strategies, and interventions*. At the highest level of abstraction, theories intend to explain human functioning and pathology. At the lowest level of abstraction, techniques which are linked to specific theories intend to generate change. And strategies are within the middle level of abstraction which can be activated by different techniques. It seems that experienced therapists consider these strategies or change processes as a heuristic guide in their practice [21]. For example, the therapists deliberately can choose from seemingly different techniques (e.g., cognitive restructuring, empty chair, family sculpting, paradoxical homework, etc.) when they target a particular change process (e.g., detriangling from parents), which meets the therapy goal (improve-

**4**

ment of depression).

factors.

Client factors include a set of characteristics (e.g., motivation, spirituality and religious faith, cognitive ability, self-agency, cooperation on therapeutic tasks, perseverance, expectations) that are potential resources that relate to clients' movement toward their therapy goal. Unfortunately, professional centrism caused the field to overlook the invaluable therapeutic potency of client factors [8, 26]. Clients usually edit and reconstruct therapeutic interventions and the therapist's style to individualize them to their values and goals. According to Miller and associates [27], "The research literature makes it clear that the client is actually the single most potent contributor to outcome in psychotherapy."

#### **2.2 Therapist factors**

Researchers proposed a set of characteristics for therapists (e.g., therapist positivity and friendliness, level of activity in the session, providing structure to face clients with cognitive, emotional, and behavioral experiences, therapist openness, therapist's ability to adapt to client's preferences, therapist's cultural sensitivity) that contribute in therapy outcome [3, 8]. Researchers using Randomized Clinical Trials (RCTs) studies usually try to control the therapist's variables. However, reanalysis of the most comprehensive evidence-based study on depression (American Psychological Association, Task Force, 1993) identified therapist effectiveness as the main treatment factor; while the treatment models, settings, and even the experience level of therapists were controlled [25]. Also, a meta-analysis of psychotherapy outcome studies [3] has found that clinicians' differences contributed more effect size (0.65) to outcome variance than the treatment models themselves (0.20). Therefore, the therapist's role in therapy outcome is sometimes referred to as a "neglected variable" [28]. Consequently, more research on therapist's competency

is critically needed, both for research and training purposes. More specifically, research can explore the core competencies that a systemic therapist needs in working with couple and family systems.

#### **2.3 Relationship factors**

Relationship factors are associated with the therapeutic alliance, which involves three components: Bonds, Tasks, and Goals. Bordin [29] defined these components as follows: Bonds refer to the nature of affection in the therapeutic relationship, such as caring, warmth, etc.; Tasks refer to the client and therapist's agreement on therapeutic activities and their credibility; Goals refer to the client and therapist's agreement and cooperation toward what they hope to achieve in therapy. The link between therapeutic alliance and outcome has been well-studied in both psychotherapy and family therapy, though the nature of alliance is more complicated in relational therapy [30, 31].

#### **2.4 Hope factors**

Being in therapy, a perceived healing process, itself generates hope in the client; which then contributes to the client's motivation and engagement [15]. However, the presence in therapy itself is not the determinant factor of the client's hope. This is because we assume therapeutic hope is a multifactorial dynamic phenomenon and a product of the interaction between therapist, client, their relationship, and contextual factors, plus the therapeutic rationale. Though the clients enter with different levels of hope and motivation, therapists apply different strategies to increase hope [32, 33]. Sprenkle and Blow [22] suggest that the field needs more research to explore the relationship between hope and change process, and how best to enhance client hope. This is potentially a more challenging theme in relational therapy; since a part of the client's system often becomes hopeless or reluctant while the other part is pushing for change.

#### **2.5 Non-specific mechanisms**

Though specific theories use different theoretical concepts and terminology and apply their own specific techniques, all those techniques can be defined in three general categories: Behavioral regulation, Cognitive mastery, and Affective experiencing [20]. That is, two different theory-specific techniques (e.g., family sculpting, empty chair) could activate the same emotional processing/regulation in the client system. Prochaska and Norcross [21] refer to such events as change processes that function between theory level and technique level; which are heuristic strategies used by experienced therapists.

#### **2.6 Common MFT/systemic factors**

Family therapists generally identify the field of MFT as a distinct profession because of the systemic epistemology that shifts the focus from the individual to relationship patterns. That is, we live in relational systems in which problems develop and solutions can be created [34]. Accordingly, interviewing a youth without the family makes it more difficult to understand and change his/her problem, and identifying one family member as the entire problem is both wrong from a relational lens and also less helpful [35]. So, the systemic epistemology guides problem definition, treatment rationale, and therapy goals in a manner that is different from those typically associated with individual therapy. All MFT therapies, to varying

**7**

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

extents, share these common mechanisms: (1) relational conceptualization of problems, (2) disrupting dysfunctional relational patterns, (3) expanding the direct

Advocates of the model specificity have mentioned a few critiques of the common factors model, including: (a) the support for a common factors model mostly comes from meta-analyses that indicated the equivalency of outcomes across treatment models, so it might not scrutinize some potential differentiating variables between models; (b) the common factors need better operational definitions to be researched and understood; (c) there is lack of evidence to show a specific link between the function of particular common factors and therapy outcome; (d) there is a lack of research that compares therapeutic impact of common factors versus model-specific factors; and (e) finally the CFs model is lacking a temporal and conceptual framework to guide therapists over the course of therapy [9, 10].

We believe these critiques are reasonable and should be addressed by multiple research methods to improve the CFs model as an integrative or metatheoretical approach. The results of meta-analyses on outcome equivalency can be interpreted in at least three ways: first, different models may generate the same efficacy but through different mechanisms of change; second, there might be significant differences between therapies' outcome, but we have not used the right research questions/measures/methods to find them; and third, the common change mechanisms can explain the equivalency of outcomes and possible minimal differences [11].

Since the focus of model specificity research is on efficacy and therapy outcome, the advocates of RCTs/ESTs "incorrectly presumed that therapy was consistently applied across therapists and within each case" ([11], p. 3). That is, most RCTs neglected the therapist and client's factors and their phenomenological experiences, which is a significant source of therapeutic variance [7, 15]. As Kazdin [36] mentioned, "many researchers lament that the manuals, including their own, are incomplete and do not reflect the complexity of treatment and scope of the exchanges

Meta-analysis research also cannot adequately explain the therapy process, since its results are built on the RCTs data with little attention to the specific therapeutic mechanisms at work. Likewise, the advocates of model specificity camp believe the current CFs approach overlooks the convolution of therapeutic change and the multilevel reality of practice. More specifically, Sexton et al., [10] concluded that "Two reasons lead us to this conclusion. First, common factors are not conceptually clear, operationally defined, or contextualized within a clinical process enough to make them either researchable or understandable. Second, as currently described, common factors are independent factors that are decontextualized from the com-

Neither manualized ESTs nor huge meta-analysis studies can unfold the mechanisms of change in therapy [11, 23]. The core phenomenon in clinical/MFT theories is to explain the process (when and how) of change, and a key reason for the development of integrative models is to maximize the therapeutic change by making use of multiple therapeutic skills. Similarly, the common factors model can play an integrative role in training, practice, and research. It would certainly help, though, if there were clearer definitions of the factors and their interactions; the context and mechanisms through which the factors are activated; and the temporal order they should be used to achieve both proximal and distal outcomes [5, 11]. Such process-progress research can help to capture the therapist and client's

therapeutic system, and (4) expanding the therapeutic alliance [22].

**3. Debate on common factors and model specificity**

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

between therapist and patient" (p. 293).

plex process of therapy" (p. 137).

extents, share these common mechanisms: (1) relational conceptualization of problems, (2) disrupting dysfunctional relational patterns, (3) expanding the direct therapeutic system, and (4) expanding the therapeutic alliance [22].

#### **3. Debate on common factors and model specificity**

Advocates of the model specificity have mentioned a few critiques of the common factors model, including: (a) the support for a common factors model mostly comes from meta-analyses that indicated the equivalency of outcomes across treatment models, so it might not scrutinize some potential differentiating variables between models; (b) the common factors need better operational definitions to be researched and understood; (c) there is lack of evidence to show a specific link between the function of particular common factors and therapy outcome; (d) there is a lack of research that compares therapeutic impact of common factors versus model-specific factors; and (e) finally the CFs model is lacking a temporal and conceptual framework to guide therapists over the course of therapy [9, 10].

We believe these critiques are reasonable and should be addressed by multiple research methods to improve the CFs model as an integrative or metatheoretical approach. The results of meta-analyses on outcome equivalency can be interpreted in at least three ways: first, different models may generate the same efficacy but through different mechanisms of change; second, there might be significant differences between therapies' outcome, but we have not used the right research questions/measures/methods to find them; and third, the common change mechanisms can explain the equivalency of outcomes and possible minimal differences [11].

Since the focus of model specificity research is on efficacy and therapy outcome, the advocates of RCTs/ESTs "incorrectly presumed that therapy was consistently applied across therapists and within each case" ([11], p. 3). That is, most RCTs neglected the therapist and client's factors and their phenomenological experiences, which is a significant source of therapeutic variance [7, 15]. As Kazdin [36] mentioned, "many researchers lament that the manuals, including their own, are incomplete and do not reflect the complexity of treatment and scope of the exchanges between therapist and patient" (p. 293).

Meta-analysis research also cannot adequately explain the therapy process, since its results are built on the RCTs data with little attention to the specific therapeutic mechanisms at work. Likewise, the advocates of model specificity camp believe the current CFs approach overlooks the convolution of therapeutic change and the multilevel reality of practice. More specifically, Sexton et al., [10] concluded that "Two reasons lead us to this conclusion. First, common factors are not conceptually clear, operationally defined, or contextualized within a clinical process enough to make them either researchable or understandable. Second, as currently described, common factors are independent factors that are decontextualized from the complex process of therapy" (p. 137).

Neither manualized ESTs nor huge meta-analysis studies can unfold the mechanisms of change in therapy [11, 23]. The core phenomenon in clinical/MFT theories is to explain the process (when and how) of change, and a key reason for the development of integrative models is to maximize the therapeutic change by making use of multiple therapeutic skills. Similarly, the common factors model can play an integrative role in training, practice, and research. It would certainly help, though, if there were clearer definitions of the factors and their interactions; the context and mechanisms through which the factors are activated; and the temporal order they should be used to achieve both proximal and distal outcomes [5, 11]. Such process-progress research can help to capture the therapist and client's

*Family Therapy - New Intervention Programs and Researches*

working with couple and family systems.

**2.3 Relationship factors**

relational therapy [30, 31].

**2.4 Hope factors**

is pushing for change.

**2.5 Non-specific mechanisms**

used by experienced therapists.

**2.6 Common MFT/systemic factors**

is critically needed, both for research and training purposes. More specifically, research can explore the core competencies that a systemic therapist needs in

Relationship factors are associated with the therapeutic alliance, which involves three components: Bonds, Tasks, and Goals. Bordin [29] defined these components as follows: Bonds refer to the nature of affection in the therapeutic relationship, such as caring, warmth, etc.; Tasks refer to the client and therapist's agreement on therapeutic activities and their credibility; Goals refer to the client and therapist's agreement and cooperation toward what they hope to achieve in therapy. The link between therapeutic alliance and outcome has been well-studied in both psychotherapy and family therapy, though the nature of alliance is more complicated in

Being in therapy, a perceived healing process, itself generates hope in the client; which then contributes to the client's motivation and engagement [15]. However, the presence in therapy itself is not the determinant factor of the client's hope. This is because we assume therapeutic hope is a multifactorial dynamic phenomenon and a product of the interaction between therapist, client, their relationship, and contextual factors, plus the therapeutic rationale. Though the clients enter with different levels of hope and motivation, therapists apply different strategies to increase hope [32, 33]. Sprenkle and Blow [22] suggest that the field needs more research to explore the relationship between hope and change process, and how best to enhance client hope. This is potentially a more challenging theme in relational therapy; since a part of the client's system often becomes hopeless or reluctant while the other part

Though specific theories use different theoretical concepts and terminology and apply their own specific techniques, all those techniques can be defined in three general categories: Behavioral regulation, Cognitive mastery, and Affective experiencing [20]. That is, two different theory-specific techniques (e.g., family sculpting, empty chair) could activate the same emotional processing/regulation in the client system. Prochaska and Norcross [21] refer to such events as change processes that function between theory level and technique level; which are heuristic strategies

Family therapists generally identify the field of MFT as a distinct profession because of the systemic epistemology that shifts the focus from the individual to relationship patterns. That is, we live in relational systems in which problems develop and solutions can be created [34]. Accordingly, interviewing a youth without the family makes it more difficult to understand and change his/her problem, and identifying one family member as the entire problem is both wrong from a relational lens and also less helpful [35]. So, the systemic epistemology guides problem definition, treatment rationale, and therapy goals in a manner that is different from those typically associated with individual therapy. All MFT therapies, to varying

**6**

phenomenological experiences, which can shed light on the change mechanisms at different stages of therapy [11, 37]. Any research to this end, can contribute to the development of more effective integrative and clinically relevant theories, and overcome a research-practice gap in the MFT field [5, 8, 11]. Process-progress research can be conducted in different forms and based on a variety of measures. For this chapter, we focus primarily on an exploratory qualitative study that examines the therapist's phenomenological experience of using common factors at three stages of therapy. In the next section, we briefly discuss the research procedures and the findings that suggest a chronological map of using CFs.

#### **4. Research design**

Qualitative research is appropriate when theory about a phenomenon is lacking or needs improvement [38]. We used a qualitative research design to address our research goal to improve the theorization of the common factors approach. We considered our project as process research or discovery-oriented research; which is concerned with what is happening in the course of therapy [37]. One assumption of such a research method is that the therapist and client behaviors occur differently at various stages of therapy. That is, even the same act/intervention (e.g., alliance, therapist competence) can be used in different contexts and for different purposes. Based on literature [22, 39, 40] we considered three stages of therapy (initial, intermediate, termination), with the assumption that each stage requires a particular set of CFs, specific interaction between the factors, and different phase-based functions/ purposes. Since we aimed to get an in-depth understanding of the phenomenon, we used open-ended questions with a focus on participants' phenomenological experience. We used validation strategies such as having other researchers review our procedures, and eliciting feedback from our participants through member checks [38].

#### **4.1 Sampling and participants**

A purposeful/theoretical sampling method was used to recruit an expert panel. The goal of theoretical sampling is to find participants who are the most knowledgeable people in the field of study [38]. Our panel consisted of six experts who were willing to provide in-depth and interactional discussion on a Wiki site designed for this purpose. (As is typical of studies of expert opinion, such as Delphi studies, the backgrounds of the participants are more important than the number of participants.). The inclusion criteria for the expert panel included: Ph.D. degree in a mental health field, publication (peer-reviewed articles, book, dissertation) in common factors/integrative therapy, and more than 10 years of teaching and training experience. Our participants' fields of study included clinical psychology, marriage, and family therapy, and counseling. As for clinical orientation, the participants identified themselves as eclectic CBT, integrative psychodynamic, and integrative family systems therapy.

#### **4.2 Data collection**

A Wiki page including instruction and three open-ended questions was created. The Wiki allows participants to discuss their own experiences and interactively comment on others. The participants were not told the identity of the other participants to keep the influence of particularly well-known participants to a minimum. The data was considered the results of the participant's opinions and the results of their shared Wiki conversations [41]. The Wiki webpage began with an explanation

**9**

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

that included: the research goal and current research gap in common factors; a brief definition of common factors to make sure all participants had similar definitions of common factors; and three open-ended questions related to a successful (70% improvement) relational (couple/family) therapy case that they previously worked

1.How and what common factors did you use to bring about change in the initial

2.How and what common factors did you use to bring about change in the

3.How and what common factors did you use to bring about change in the

The Wiki space was available for 2 weeks, which allowed the participants to come back and complete/edit their work or comment on others' posts. We assigned separate questions for each stage of therapy to collect information related to differ-

Thematic analysis (TA) was used to identify those patterns that were relevant to the specific research question [42]. That is, when and how do expert therapists use common factors in the course of therapy to reach their desired therapeutic outcomes? We conducted thematic analysis both inductively (bottom-up approach) and deductively (top-down approach). The inductive approach created opportunity for development of new themes of common factors (therapy principles) as well as provided explanation that how and when therapist uses particular common factors at specific points of time in therapy (therapeutic procedures). On the other hand, we employed a deductive analysis, as well, because we had predetermined assumptions and definitions of CFs components [22]. In order to increase the rigor of our data, we employed multiple levels of data analysis, from the narrow codes to more abstract dimensions and interpretations. We used Braun & Clarke's [42] framework of thematic analysis, including: (1) Familiarizing yourself with the data, (2) Generating initial codes, (3) Searching for themes, (4) Reviewing potential themes,

Using thematic analysis, several codes emerged, and specific themes were developed for the initial, intermediate, and termination stages of therapy, including five themes for the initial stage, five themes for the intermediate stage, and four themes for the termination stage (see **Table 1**). The final themes and their definitions for

Though this theme emerged initially in the first stage of therapy, it continued over the intermediate and termination stage too. This theme refers to the therapists' general

ential common factors they may have used at different therapy stages.

(5) Defining and naming themes, (6) Producing the report.

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

intermediate stage of therapy?

termination stage of therapy?

with. The questions posed were:

stage of therapy?

**4.3 Data analysis**

**5. Research findings**

each stage are discussed here:

**5.1 Initial stage**

*5.1.1 Time planning*

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

that included: the research goal and current research gap in common factors; a brief definition of common factors to make sure all participants had similar definitions of common factors; and three open-ended questions related to a successful (70% improvement) relational (couple/family) therapy case that they previously worked with. The questions posed were:


The Wiki space was available for 2 weeks, which allowed the participants to come back and complete/edit their work or comment on others' posts. We assigned separate questions for each stage of therapy to collect information related to differential common factors they may have used at different therapy stages.

#### **4.3 Data analysis**

*Family Therapy - New Intervention Programs and Researches*

findings that suggest a chronological map of using CFs.

**4. Research design**

**4.1 Sampling and participants**

integrative family systems therapy.

**4.2 Data collection**

phenomenological experiences, which can shed light on the change mechanisms at different stages of therapy [11, 37]. Any research to this end, can contribute to the development of more effective integrative and clinically relevant theories, and overcome a research-practice gap in the MFT field [5, 8, 11]. Process-progress research can be conducted in different forms and based on a variety of measures. For this chapter, we focus primarily on an exploratory qualitative study that examines the therapist's phenomenological experience of using common factors at three stages of therapy. In the next section, we briefly discuss the research procedures and the

Qualitative research is appropriate when theory about a phenomenon is lacking or needs improvement [38]. We used a qualitative research design to address our research goal to improve the theorization of the common factors approach. We considered our project as process research or discovery-oriented research; which is concerned with what is happening in the course of therapy [37]. One assumption of such a research method is that the therapist and client behaviors occur differently at various stages of therapy. That is, even the same act/intervention (e.g., alliance, therapist competence) can be used in different contexts and for different purposes. Based on literature [22, 39, 40] we considered three stages of therapy (initial, intermediate, termination), with the assumption that each stage requires a particular set of CFs, specific interaction between the factors, and different phase-based functions/ purposes. Since we aimed to get an in-depth understanding of the phenomenon, we used open-ended questions with a focus on participants' phenomenological experience. We used validation strategies such as having other researchers review our procedures, and eliciting feedback from our participants through member checks [38].

A purposeful/theoretical sampling method was used to recruit an expert panel. The goal of theoretical sampling is to find participants who are the most knowledgeable people in the field of study [38]. Our panel consisted of six experts who were willing to provide in-depth and interactional discussion on a Wiki site designed for this purpose. (As is typical of studies of expert opinion, such as Delphi studies, the backgrounds of the participants are more important than the number of participants.). The inclusion criteria for the expert panel included: Ph.D. degree in a mental health field, publication (peer-reviewed articles, book, dissertation) in common factors/integrative therapy, and more than 10 years of teaching and training experience. Our participants' fields of study included clinical psychology, marriage, and family therapy, and counseling. As for clinical orientation, the participants identified themselves as eclectic CBT, integrative psychodynamic, and

A Wiki page including instruction and three open-ended questions was created. The Wiki allows participants to discuss their own experiences and interactively comment on others. The participants were not told the identity of the other participants to keep the influence of particularly well-known participants to a minimum. The data was considered the results of the participant's opinions and the results of their shared Wiki conversations [41]. The Wiki webpage began with an explanation

**8**

Thematic analysis (TA) was used to identify those patterns that were relevant to the specific research question [42]. That is, when and how do expert therapists use common factors in the course of therapy to reach their desired therapeutic outcomes? We conducted thematic analysis both inductively (bottom-up approach) and deductively (top-down approach). The inductive approach created opportunity for development of new themes of common factors (therapy principles) as well as provided explanation that how and when therapist uses particular common factors at specific points of time in therapy (therapeutic procedures). On the other hand, we employed a deductive analysis, as well, because we had predetermined assumptions and definitions of CFs components [22]. In order to increase the rigor of our data, we employed multiple levels of data analysis, from the narrow codes to more abstract dimensions and interpretations. We used Braun & Clarke's [42] framework of thematic analysis, including: (1) Familiarizing yourself with the data, (2) Generating initial codes, (3) Searching for themes, (4) Reviewing potential themes, (5) Defining and naming themes, (6) Producing the report.

#### **5. Research findings**

Using thematic analysis, several codes emerged, and specific themes were developed for the initial, intermediate, and termination stages of therapy, including five themes for the initial stage, five themes for the intermediate stage, and four themes for the termination stage (see **Table 1**). The final themes and their definitions for each stage are discussed here:

#### **5.1 Initial stage**

#### *5.1.1 Time planning*

Though this theme emerged initially in the first stage of therapy, it continued over the intermediate and termination stage too. This theme refers to the therapists' general


#### **Table 1.**

*A chronological map of common factors.*

strategy in prioritizing particular common factors at each moment throughout the course of therapy. The experts believed that such planning worked as a heuristic strategy that helps them map the sequence of actions in the course of therapy. That is, the expert panel explained they would not jump into task/homework assignments before they built a strong alliance with each client and facilitated hope, motivation, problem rationale, and treatment rationale. For example, during the early sessions, the therapist initially works on therapeutic hope and persuasiveness. For example, one expert stated: *"I think common factors are MOST applicable early in therapy,"* specifically this expert would focus on supporting the client's decision to come to therapy and explaining how therapy might be helpful if the client system *"came reluctantly to treatment because he was embarrassed that he needed help. His expectations were low and he had misgivings about whether psychological interventions could help."*

#### *5.1.2 Hope and motivation are primary goals*

This theme indicates that the experts intentionally prioritize the client's hope and motivation in early sessions of therapy, rather than just listening to the client's problem narrative. Though, the expert panel identified with different theoretical backgrounds, all emphasized the development of hope and motivation as their proximal goal in early stage ("*I gained their trust, engendered hope,..."*). Previous research also indicates that both the common factors approach and the model specific treatments approach emphasize the important role of hope and motivation in the early stage of therapy [23, 33]. For example, Functional Family Therapy (FFT) [43] specifically focuses on hope in the first phase of FFT (labeled inductionmotivation). That is, the therapist actively works to get the client to believe that the problem can change and that the therapist and therapy would promote the change ("*taking a system from 'demoralized' to 'remoralized' taps into a powerful therapist and client common factors*.").

#### *5.1.3 Systemic alliance in early stage*

This theme refers to specific points: First, building an alliance with all family members is a unique challenge in relational therapies *("I believe the difficulty in working with a system initially, is that different members of system come in with* 

**11**

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

*different goals"*). Second, such alliance in early sessions is accomplished through specific mechanisms: (a) an affective bonds with all members by empathy and validation of their positions *("we gained buy-in and a strong relationship with all members of this family through validating their positions, using their points of view, and aligning with their goals"…"and bonds with all involved (empathy, validation and support)"*); (b) a goal agreement ("*Establishing an alliance early on, especially on the goals dimensions, is a power common factor in early stage therapy"*). Based on our data, we assume the third component (tasks agreement) of alliance usually occurs in the

This theme, in relational therapies, refers to a general cognitive-systemic procedure that alters the meaning of the client's perceived problem and its relational context. The therapist challenges the definition of the client's presenting problem and creates a new contextual lens; in which the blaming of self and others faded away and so the possibility of transition from stuck position seems doable *("He had an affair to which she responded in part by starting to drink again after many years of sobriety" or "I offered a clear rationale for each party of the system"*). Therefore, it

Our data indicate the relational conceptualization of the problem (systemic reframing) not only generates a new systemic lens but also unites the members toward the benefit of the whole system, so contributes both in hope and the withinfamily alliance [35, 44–46]. Systemic reframing function across all MFT models. For example, Bowen challenges the most "subjective face" of the problem. Haley and the Mental Research Institute (MRI) group challenge "the more of the same," and White challenges the "social dominant systems." Despite the widespread use of reframing in therapy, there is a lack of empirical evidence to explain the impact of this mechanism on family interaction and therapy outcome [33]. Alexander et al. [47] showed lower defensive behaviors following reframe intervention than other

types of therapist's interventions (reflection, restructuring statements).

This theme refers to the fact that the hope and motivation as the primary goal of the early stage can be developed via multiple pathways; which are due to a variety of factors (the therapist and client's characteristics, clinical settings, clinical problem, session formats, etc.). Some of the experts achieved the goal through relationship factors and the therapist's presence (e. g., "*I tried hard to maintain a non-reactive presence and validate each of their positions in order to establish safety and increase hope"…"this formed a strong relationship, …, and engendered hope" or "I also want to emphasize that the most important common factors are reflected more in who the therapist 'is' rather than what the therapist 'does'."*), which is consistent with some theories (Attachment, Bowenian, Experiential, Emotion-focused). That is, people will be hopeful and explorative when they find themselves in a safe and secure relationship [37]. Other expert used his own expertise/competency (therapist factors) to build trust and, in turn, hope in the client system *("… to let them know that even though they are freaking out and do not see a way out of it all, it is something that I have seen often, understand, and know how to handle"*), this could be consistent with the

The other mechanisms were problem explanation, goal setting, and treatment rationale that fitted with client's worldview to develop hope and motivation (*e.g., "offered a clear rationale for each party of the system" or "It was also critical that I* 

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

intermediate stage of therapy.

*5.1.4 Reframing as a general cognitive-systemic mechanism*

implies that change is doable and so hope is engendered.

*5.1.5 Hope and motivation achieved through different paths*

Structural-Strategic model [44, 45].

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

*different goals"*). Second, such alliance in early sessions is accomplished through specific mechanisms: (a) an affective bonds with all members by empathy and validation of their positions *("we gained buy-in and a strong relationship with all members of this family through validating their positions, using their points of view, and aligning with their goals"…"and bonds with all involved (empathy, validation and support)"*); (b) a goal agreement ("*Establishing an alliance early on, especially on the goals dimensions, is a power common factor in early stage therapy"*). Based on our data, we assume the third component (tasks agreement) of alliance usually occurs in the intermediate stage of therapy.

#### *5.1.4 Reframing as a general cognitive-systemic mechanism*

This theme, in relational therapies, refers to a general cognitive-systemic procedure that alters the meaning of the client's perceived problem and its relational context. The therapist challenges the definition of the client's presenting problem and creates a new contextual lens; in which the blaming of self and others faded away and so the possibility of transition from stuck position seems doable *("He had an affair to which she responded in part by starting to drink again after many years of sobriety" or "I offered a clear rationale for each party of the system"*). Therefore, it implies that change is doable and so hope is engendered.

Our data indicate the relational conceptualization of the problem (systemic reframing) not only generates a new systemic lens but also unites the members toward the benefit of the whole system, so contributes both in hope and the withinfamily alliance [35, 44–46]. Systemic reframing function across all MFT models. For example, Bowen challenges the most "subjective face" of the problem. Haley and the Mental Research Institute (MRI) group challenge "the more of the same," and White challenges the "social dominant systems." Despite the widespread use of reframing in therapy, there is a lack of empirical evidence to explain the impact of this mechanism on family interaction and therapy outcome [33]. Alexander et al. [47] showed lower defensive behaviors following reframe intervention than other types of therapist's interventions (reflection, restructuring statements).

#### *5.1.5 Hope and motivation achieved through different paths*

This theme refers to the fact that the hope and motivation as the primary goal of the early stage can be developed via multiple pathways; which are due to a variety of factors (the therapist and client's characteristics, clinical settings, clinical problem, session formats, etc.). Some of the experts achieved the goal through relationship factors and the therapist's presence (e. g., "*I tried hard to maintain a non-reactive presence and validate each of their positions in order to establish safety and increase hope"…"this formed a strong relationship, …, and engendered hope" or "I also want to emphasize that the most important common factors are reflected more in who the therapist 'is' rather than what the therapist 'does'."*), which is consistent with some theories (Attachment, Bowenian, Experiential, Emotion-focused). That is, people will be hopeful and explorative when they find themselves in a safe and secure relationship [37]. Other expert used his own expertise/competency (therapist factors) to build trust and, in turn, hope in the client system *("… to let them know that even though they are freaking out and do not see a way out of it all, it is something that I have seen often, understand, and know how to handle"*), this could be consistent with the Structural-Strategic model [44, 45].

The other mechanisms were problem explanation, goal setting, and treatment rationale that fitted with client's worldview to develop hope and motivation (*e.g., "offered a clear rationale for each party of the system" or "It was also critical that I* 

*Family Therapy - New Intervention Programs and Researches*

Hope and motivation are primary goals Family Alliance in early stage

Expanding the direct therapeutic system

Maintain achieved goals through different paths

1 Time planning

2 Engagement in therapeutic tasks

Feedback loop Split Family Alliance

3 Attribution of success

*A chronological map of common factors.*

**Table 1.**

Facing new experiences Trend of progress and relapse

Inoculation of future relapse Extended therapeutic alliance

**Stage Mechanisms of change Goal**

Hope and motivation

Maintaining the goal

patterns

Engagement in new functional

Reframing as a general cognitive-systemic mechanism Hope and motivation achieved through different paths

*about whether psychological interventions could help."*

*5.1.2 Hope and motivation are primary goals*

strategy in prioritizing particular common factors at each moment throughout the course of therapy. The experts believed that such planning worked as a heuristic strategy that helps them map the sequence of actions in the course of therapy. That is, the expert panel explained they would not jump into task/homework assignments before they built a strong alliance with each client and facilitated hope, motivation, problem rationale, and treatment rationale. For example, during the early sessions, the therapist initially works on therapeutic hope and persuasiveness. For example, one expert stated: *"I think common factors are MOST applicable early in therapy,"* specifically this expert would focus on supporting the client's decision to come to therapy and explaining how therapy might be helpful if the client system *"came reluctantly to treatment because he was embarrassed that he needed help. His expectations were low and he had misgivings* 

This theme indicates that the experts intentionally prioritize the client's hope and motivation in early sessions of therapy, rather than just listening to the client's problem narrative. Though, the expert panel identified with different theoretical backgrounds, all emphasized the development of hope and motivation as their proximal goal in early stage ("*I gained their trust, engendered hope,..."*). Previous research also indicates that both the common factors approach and the model specific treatments approach emphasize the important role of hope and motivation in the early stage of therapy [23, 33]. For example, Functional Family Therapy (FFT) [43] specifically focuses on hope in the first phase of FFT (labeled inductionmotivation). That is, the therapist actively works to get the client to believe that the problem can change and that the therapist and therapy would promote the change ("*taking a system from 'demoralized' to 'remoralized' taps into a powerful therapist and* 

This theme refers to specific points: First, building an alliance with all family members is a unique challenge in relational therapies *("I believe the difficulty in working with a system initially, is that different members of system come in with* 

**10**

*client common factors*.").

*5.1.3 Systemic alliance in early stage*

*honored each party's position on the nature of the problem, their values, language, and their goals"*). Also, some of the experts used "breaking dysfunctional patterns" which contributed to hope and motivation through reduction of negativity and blaming in the client's system [33, 45]. The following excerpts illustrate that CFs are not just a list of static factors, but they are prioritized and interactively used to create a context of change *("I think of common factors as dynamic processes within the larger context of change," or, "Early in treatment as we developed a relationship of trust and warmth and as he learned about treatment, he begins to have hope that he might benefit from treatment. As you can see from this, some therapist, relationship, and hope components were evident. I was using a CBT approach to treatment"*). So, we assume that these hope-generating mechanisms function beyond a specific theory or model, but within the therapeutic participants.

#### **5.2 Intermediate stage**

#### *5.2.1 Engagement in therapeutic tasks*

This theme refers to the process in which the therapist works with the client system on the assumption that change requires action and responsibility. This process is based on previously activated client's factors (such as hope and motivation, etc.), therapist's factors (support, expertise, etc.), relationship factors (bonds, trust, etc.), and the problem explanation and treatment rationale *("During the middle phase of treatment, I maintained my treatment rationale (chosen to fit with these clients and the way they viewed their problems)"*). Our participants' experiences indicate some clients easily engage in therapeutic tasks while others are reluctant; which demands the therapist to actively work on this process to get the client system engaged *("The case I'm thinking about was unique…..they were all seen as resistant or reactive to treatment"…"I gained their trust, engendered hope, and offered a clear rationale for each party of the system"*). Our findings suggest that this mechanism is used by all models. However, the client characteristics and the type of problem determine to what extent a therapist should work on this mechanism *("I also adapted to their personalities by pushing and challenging them pretty directly throughout this stage – an approach they liked"*). For example, the therapy dropout rates for youth with behavioral and drug problems are estimated from 50–75% [48], which can explain why FFT specifically emphasizes on engagement and motivation of youth and families in early stage of therapy [47].

#### *5.2.2 Expanding the direct therapeutic system*

This theme refers to the therapist intention to expand the therapeutic contact to other family members or systems who can facilitate therapeutic change. *("Mom brought boyfriend into the relationship and they both set clear limits and expectations {for the son}"*). This is another unique systemic CFs that function across MFT therapies, specifically integrative models. For example, multisystemic family therapy (MSFT) expands therapeutic interventions to the wider school and interagency network [49]. The degree of such expansion is based on the relational conceptualization of the problem at stage one as well as the ongoing feedback from the client system to therapy interventions.

#### *5.2.3 Facing new experiences (emotional, cognitive, behavioral)*

This theme refers to any new cognitive, behavioral, and emotional experience that helps the client to achieve therapeutic goals. They are new functional patterns

**13**

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

that are challenging pathways to achieve therapeutic goals. Some experts used cognitive strategies *("his insights were also related to the CBT intervention"*) versus others that used emotional strategies ("*processed a lot ala EFT*"), and others used behavioral strategies ("*I develop task assignments aimed at interrupting patterns"…"son began doing his homework and was rewarded by going to work in doing some construction jobs with [the mom's]boyfriend"*). The critical point is the overlap between these apparently content-distinct interventions which all finally result in the same functional pattern (process) in the client system. That is, from an experiential lens there is a concurrent experience of emotional, behavioral, and cognitive aspects in real life. For example, the "blamer softening" technique in EFT is considered primarily an emotional processing intervention but in fact it is associated with promotion in both intrapersonal awareness and interpersonal restructuring of interactions [37]. That is, an emotional schema of self and others changes which, in turn, triggers new behaviors from the partner. However, we assume the therapist's style and client's characteristics and feedback could guide which type of these three mechanisms would be more desirable and applicable. *("I was calm (that's my overall style/personality anyway*," or "*My position with her son was to commiserate with his distress over Dad and to empathize with him over how his mother was treating him like a child"*). Even within an evidencebased treatment like Emotion-Focused Therapy (EFT), the therapist's emotional presence (e.g., manner of emotional responsiveness and softened vocal quality) predicts heightened levels of client emotional experience in successful "Blamer Softening," which is a unique indicator of successful therapy [50]. As Lebow [5] noted "therapists vary enormously," so the same cognitive technique, for example, can function unevenly in the change process due to such an enormous variety.

In addition, these new experiences can be done either in the session *("allowing clients to explore safely their relational problems with the therapist in the 'here and now' context of the therapeutic relationship"*), or out-of-therapy session ("*Son was allowed more freedom and complied by returning home early and pitching in with home chores*."). This distinction between in-session and out-of-session tasks itself is an

This theme refers to a natural trend of progress and relapse in an intermediate stage of therapy. The experts described it as a process in which the client system normally experiences ups and downs to achieve a new functional pattern, though progressively toward more competence ("*There was a lot of progress, followed by relapse, then progress, then relapse, etc.," or, "'I believe that a successful' 'tear and repair' in the intermediate stage of therapy will strengthen the overall therapeutic alliance by allowing clients to explore safely their relational problems"*). Expert therapists anticipated such a trend, so they inform and inoculate their clients in advance regarding of the trend ("*I have learned to offer inoculations….. to help with this", "you may notice early improvement followed by a backslide"*). By doing precedent inoculation, the therapist prevents hopelessness and alliance rupture as well as inspires more client's

Also, it seems the conceptualization of this trend goes beyond individual therapy and contains a wider contextual lens. Our findings indicate a reaction by the client's family of origins and their work following therapeutic change during the intermediate stage *("there were extratherapeutic factors happened in each of their families as well as their work lives that essentially forced them to either turn towards or* 

Another sub-theme related to the "trend of progress and relapse" was "ongoing mutual feedback"; which helped the experts to continuously adjust

*away from each other. Therapy helped guide that change"*).

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

important research topic in the MFT field.

*5.2.4 Trend of progress and relapse*

persistence and engagement.

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

that are challenging pathways to achieve therapeutic goals. Some experts used cognitive strategies *("his insights were also related to the CBT intervention"*) versus others that used emotional strategies ("*processed a lot ala EFT*"), and others used behavioral strategies ("*I develop task assignments aimed at interrupting patterns"…"son began doing his homework and was rewarded by going to work in doing some construction jobs with [the mom's]boyfriend"*). The critical point is the overlap between these apparently content-distinct interventions which all finally result in the same functional pattern (process) in the client system. That is, from an experiential lens there is a concurrent experience of emotional, behavioral, and cognitive aspects in real life. For example, the "blamer softening" technique in EFT is considered primarily an emotional processing intervention but in fact it is associated with promotion in both intrapersonal awareness and interpersonal restructuring of interactions [37]. That is, an emotional schema of self and others changes which, in turn, triggers new behaviors from the partner. However, we assume the therapist's style and client's characteristics and feedback could guide which type of these three mechanisms would be more desirable and applicable. *("I was calm (that's my overall style/personality anyway*," or "*My position with her son was to commiserate with his distress over Dad and to empathize with him over how his mother was treating him like a child"*). Even within an evidencebased treatment like Emotion-Focused Therapy (EFT), the therapist's emotional presence (e.g., manner of emotional responsiveness and softened vocal quality) predicts heightened levels of client emotional experience in successful "Blamer Softening," which is a unique indicator of successful therapy [50]. As Lebow [5] noted "therapists vary enormously," so the same cognitive technique, for example, can function unevenly in the change process due to such an enormous variety.

In addition, these new experiences can be done either in the session *("allowing clients to explore safely their relational problems with the therapist in the 'here and now' context of the therapeutic relationship"*), or out-of-therapy session ("*Son was allowed more freedom and complied by returning home early and pitching in with home chores*."). This distinction between in-session and out-of-session tasks itself is an important research topic in the MFT field.

#### *5.2.4 Trend of progress and relapse*

This theme refers to a natural trend of progress and relapse in an intermediate stage of therapy. The experts described it as a process in which the client system normally experiences ups and downs to achieve a new functional pattern, though progressively toward more competence ("*There was a lot of progress, followed by relapse, then progress, then relapse, etc.," or, "'I believe that a successful' 'tear and repair' in the intermediate stage of therapy will strengthen the overall therapeutic alliance by allowing clients to explore safely their relational problems"*). Expert therapists anticipated such a trend, so they inform and inoculate their clients in advance regarding of the trend ("*I have learned to offer inoculations….. to help with this", "you may notice early improvement followed by a backslide"*). By doing precedent inoculation, the therapist prevents hopelessness and alliance rupture as well as inspires more client's persistence and engagement.

Also, it seems the conceptualization of this trend goes beyond individual therapy and contains a wider contextual lens. Our findings indicate a reaction by the client's family of origins and their work following therapeutic change during the intermediate stage *("there were extratherapeutic factors happened in each of their families as well as their work lives that essentially forced them to either turn towards or away from each other. Therapy helped guide that change"*).

Another sub-theme related to the "trend of progress and relapse" was "ongoing mutual feedback"; which helped the experts to continuously adjust

*Family Therapy - New Intervention Programs and Researches*

model, but within the therapeutic participants.

**5.2 Intermediate stage**

*5.2.1 Engagement in therapeutic tasks*

and families in early stage of therapy [47].

*5.2.2 Expanding the direct therapeutic system*

system to therapy interventions.

*5.2.3 Facing new experiences (emotional, cognitive, behavioral)*

*honored each party's position on the nature of the problem, their values, language, and their goals"*). Also, some of the experts used "breaking dysfunctional patterns" which contributed to hope and motivation through reduction of negativity and blaming in the client's system [33, 45]. The following excerpts illustrate that CFs are not just a list of static factors, but they are prioritized and interactively used to create a context of change *("I think of common factors as dynamic processes within the larger context of change," or, "Early in treatment as we developed a relationship of trust and warmth and as he learned about treatment, he begins to have hope that he might benefit from treatment. As you can see from this, some therapist, relationship, and hope components were evident. I was using a CBT approach to treatment"*). So, we assume that these hope-generating mechanisms function beyond a specific theory or

This theme refers to the process in which the therapist works with the client system on the assumption that change requires action and responsibility. This process is based on previously activated client's factors (such as hope and motivation, etc.), therapist's factors (support, expertise, etc.), relationship factors (bonds, trust, etc.), and the problem explanation and treatment rationale *("During the middle phase of treatment, I maintained my treatment rationale (chosen to fit with these clients and the way they viewed their problems)"*). Our participants' experiences indicate some clients easily engage in therapeutic tasks while others are reluctant; which demands the therapist to actively work on this process to get the client system engaged *("The case I'm thinking about was unique…..they were all seen as resistant or reactive to treatment"…"I gained their trust, engendered hope, and offered a clear rationale for each party of the system"*). Our findings suggest that this mechanism is used by all models. However, the client characteristics and the type of problem determine to what extent a therapist should work on this mechanism *("I also adapted to their personalities by pushing and challenging them pretty directly throughout this stage – an approach they liked"*). For example, the therapy dropout rates for youth with behavioral and drug problems are estimated from 50–75% [48], which can explain why FFT specifically emphasizes on engagement and motivation of youth

This theme refers to the therapist intention to expand the therapeutic contact to other family members or systems who can facilitate therapeutic change. *("Mom brought boyfriend into the relationship and they both set clear limits and expectations {for the son}"*). This is another unique systemic CFs that function across MFT therapies, specifically integrative models. For example, multisystemic family therapy (MSFT) expands therapeutic interventions to the wider school and interagency network [49]. The degree of such expansion is based on the relational conceptualization of the problem at stage one as well as the ongoing feedback from the client

This theme refers to any new cognitive, behavioral, and emotional experience that helps the client to achieve therapeutic goals. They are new functional patterns

**12**

the relationship, their conceptualization, and methods due to improvisational nature of the process ("*I also adapted to their personalities by pushing and challenging them pretty directly throughout this stage - an approach they liked," or, "the concept of giving and eliciting client feedback, is especially essential in later phases," or, "I try to balance being real and authentic about my hopes for them while at the same time creating space for them to chart the course they feel is best"*). Recently, the mutual feedback has received more attention as a critical change mechanism in therapy [5, 11].

#### *5.2.5 Split systemic alliance*

This theme refers to a common phenomenon in the intermediate stage of relational therapy in which a part of the client system experiences weaker alliance to the therapist than another part of the system [31]. It causes resistance to engage in therapeutic tasks while the therapist is aiming to unite them toward their therapy goal *("A split alliance may quickly degenerate into an alliance rupture,"…., "I continued to be open to flex as needed if their alliance was faltering in any ways"*).

To repair a split systemic alliance, the experts approached the client subsystems in one unite as a couple or family system *("I also relied on the depth of our connectionthey knew that I cared about them and that their marriage mattered to me" or "she said that she knew that I really wanted them to succeed as a couple, which kept her going"*). They used a few systemic change mechanisms, including relational conceptualization of the problem which takes away the blame from all members; presenting relational patterns as therapeutic target; disrupting conflicted family interactions to reduce negativity [7, 33]; prioritizing the wellbeing of the whole system than any individual member of the system; and presenting emotional neutrality to all members [7, 35].

#### **5.3 Termination stage**

#### *5.3.1 Attribution of success*

This theme refers to a process that helps the client system to own the therapeutic changes that have been made. That is, the client system internalizes them as a result of their efforts and skills *("I commended them for all they had done and gave them a chance to explain how they did it thus having them own the change by attributing it to themselves"*). This mechanism is consistent with the self-efficacy concept [51] that is negatively correlated with relapse [52] ("*Here, I want to make sure that I highlight what the client has done to bring about change. I will often make a list and send it home with the client").*

#### *5.3.2 Inoculation of future relapse*

This theme refers to a process in which the therapist educates the client system about the possible relapse after termination, and the strategies can be used to handle a possible relapse *("Upon successful termination, we commended all and inoculated them against inevitable backsliding and future hurdles"*). Our findings show that the experts used a feedback loop with the client system to help them gain insight about the change process, which itself is a pathway for clients to be able to handle possible future hurdles *("While important in all stages of therapy, the concept of giving and eliciting client feedback is especially essential in later phases as termination approaches"*).

**15**

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

This theme refers to the availability of the therapist after termination in case the client system needed help or support *("I extend the relationship by reframing termination as variable scheduling- the client calls me for an appointment if a need comes up"*). By doing this, the therapist intentionally expands the therapeutic alliance beyond the therapy course; which generates security and hope that can contribute

This theme refers to the mechanism that helps the client to sustain new functional patterns that they have developed in the course of therapy. That is, the client system earns a capacity to continue the therapy outcomes without depending on the therapist ("*At termination I am working clients on sustaining changes that they have made"*). To this end, the experts utilized several mechanisms: using strengths-based conversations with client; empowering the client to own the changes have been made in therapy; expanding therapeutic alliance available after termination; educating client regarding of future relapse *("A lot of strengths-based conversation and reflection on the progress they'd made, as well as inoculation against future relapse as has been mentioned by others…." "I also, prepare the client for relapse and develop plans for how to manage a relapse",.., "specific interventions ongoing to help create a situation where changes could be maintained")*.

Despite disagreements between advocates of the model-specificity approach and CFs approach on outcome equivalency, they agree that the process and progress research can shed light on the mechanisms of change; which can bridge the two approaches and contribute to the field's integration [4, 5, 8]. To this end, we presented a primarily chronological map of common factors at three stages of relational therapy, which is supported by the findings of our qualitative process

Our findings show that the experts, regardless of their theoretical lens, focused on generating hope and motivation as the primary goal of the initial stage, though they achieved it through different combinations of these CFs (using therapist presence and safe relationship, family alliance, therapist expertise/competency, relational conceptualization of problem, interrupting dysfunctional pattern, and goal agreement). It is consistent with the phased-based goals and challenges in most evidence-based treatments. For example, Functional Family Therapy [43] labels the first stage as "Induction-Motivation," or Structural Therapy [45] labels it as "Joining and Accommodation," though they may use different combinations of the above-

The priority goal in the intermediate stage was the engagement in therapeutic tasks, which calls for the client system's responsibility and action toward therapy goals. To this end, the experts utilized the therapist's presence, relationship factors, and the client's hope as a context. However, the main mechanisms were: the relational conceptualization of the problem, systemic goal agreement, and treatment rationale. By doing so, they enhance the credibility of therapy which itself is a mechanism of therapeutic change [13, 53]. As opposed to blaming clients for being uninterested or unmotivated, the experts contextualize the problem explanation and treatment rationale within the client's system and culture to enhance their

mentioned change mechanisms/CFs to achieve the same proximal goal.

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

to better maintenance of achieved goals.

*5.3.4 Maintain achieved goals*

**6. Discussion**

research and existing MFT literature.

engagement in therapy [54, 55].

*5.3.3 Extended therapeutic alliance*

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

#### *5.3.3 Extended therapeutic alliance*

*Family Therapy - New Intervention Programs and Researches*

therapy [5, 11].

*any ways"*).

members [7, 35].

*with the client").*

*5.3.2 Inoculation of future relapse*

**5.3 Termination stage**

*5.3.1 Attribution of success*

*5.2.5 Split systemic alliance*

the relationship, their conceptualization, and methods due to improvisational nature of the process ("*I also adapted to their personalities by pushing and challenging them pretty directly throughout this stage - an approach they liked," or, "the concept of giving and eliciting client feedback, is especially essential in later phases," or, "I try to balance being real and authentic about my hopes for them while at the same time creating space for them to chart the course they feel is best"*). Recently, the mutual feedback has received more attention as a critical change mechanism in

This theme refers to a common phenomenon in the intermediate stage of relational therapy in which a part of the client system experiences weaker alliance to the therapist than another part of the system [31]. It causes resistance to engage in therapeutic tasks while the therapist is aiming to unite them toward their therapy goal *("A split alliance may quickly degenerate into an alliance rupture,"…., "I continued to be open to flex as needed if their alliance was faltering in* 

To repair a split systemic alliance, the experts approached the client subsystems in one unite as a couple or family system *("I also relied on the depth of our connectionthey knew that I cared about them and that their marriage mattered to me" or "she said that she knew that I really wanted them to succeed as a couple, which kept her going"*). They used a few systemic change mechanisms, including relational conceptualization of the problem which takes away the blame from all members; presenting relational patterns as therapeutic target; disrupting conflicted family interactions to reduce negativity [7, 33]; prioritizing the wellbeing of the whole system than any individual member of the system; and presenting emotional neutrality to all

This theme refers to a process that helps the client system to own the therapeutic changes that have been made. That is, the client system internalizes them as a result of their efforts and skills *("I commended them for all they had done and gave them a chance to explain how they did it thus having them own the change by attributing it to themselves"*). This mechanism is consistent with the self-efficacy concept [51] that is negatively correlated with relapse [52] ("*Here, I want to make sure that I highlight what the client has done to bring about change. I will often make a list and send it home* 

This theme refers to a process in which the therapist educates the client system

about the possible relapse after termination, and the strategies can be used to handle a possible relapse *("Upon successful termination, we commended all and inoculated them against inevitable backsliding and future hurdles"*). Our findings show that the experts used a feedback loop with the client system to help them gain insight about the change process, which itself is a pathway for clients to be able to handle possible future hurdles *("While important in all stages of therapy, the concept of giving and eliciting client feedback is especially essential in later phases as termination* 

**14**

*approaches"*).

This theme refers to the availability of the therapist after termination in case the client system needed help or support *("I extend the relationship by reframing termination as variable scheduling- the client calls me for an appointment if a need comes up"*). By doing this, the therapist intentionally expands the therapeutic alliance beyond the therapy course; which generates security and hope that can contribute to better maintenance of achieved goals.

#### *5.3.4 Maintain achieved goals*

This theme refers to the mechanism that helps the client to sustain new functional patterns that they have developed in the course of therapy. That is, the client system earns a capacity to continue the therapy outcomes without depending on the therapist ("*At termination I am working clients on sustaining changes that they have made"*). To this end, the experts utilized several mechanisms: using strengths-based conversations with client; empowering the client to own the changes have been made in therapy; expanding therapeutic alliance available after termination; educating client regarding of future relapse *("A lot of strengths-based conversation and reflection on the progress they'd made, as well as inoculation against future relapse as has been mentioned by others…." "I also, prepare the client for relapse and develop plans for how to manage a relapse",.., "specific interventions ongoing to help create a situation where changes could be maintained")*.

#### **6. Discussion**

Despite disagreements between advocates of the model-specificity approach and CFs approach on outcome equivalency, they agree that the process and progress research can shed light on the mechanisms of change; which can bridge the two approaches and contribute to the field's integration [4, 5, 8]. To this end, we presented a primarily chronological map of common factors at three stages of relational therapy, which is supported by the findings of our qualitative process research and existing MFT literature.

Our findings show that the experts, regardless of their theoretical lens, focused on generating hope and motivation as the primary goal of the initial stage, though they achieved it through different combinations of these CFs (using therapist presence and safe relationship, family alliance, therapist expertise/competency, relational conceptualization of problem, interrupting dysfunctional pattern, and goal agreement). It is consistent with the phased-based goals and challenges in most evidence-based treatments. For example, Functional Family Therapy [43] labels the first stage as "Induction-Motivation," or Structural Therapy [45] labels it as "Joining and Accommodation," though they may use different combinations of the abovementioned change mechanisms/CFs to achieve the same proximal goal.

The priority goal in the intermediate stage was the engagement in therapeutic tasks, which calls for the client system's responsibility and action toward therapy goals. To this end, the experts utilized the therapist's presence, relationship factors, and the client's hope as a context. However, the main mechanisms were: the relational conceptualization of the problem, systemic goal agreement, and treatment rationale. By doing so, they enhance the credibility of therapy which itself is a mechanism of therapeutic change [13, 53]. As opposed to blaming clients for being uninterested or unmotivated, the experts contextualize the problem explanation and treatment rationale within the client's system and culture to enhance their engagement in therapy [54, 55].

Another important finding was a "trend of progress and relapse" in the second phase of therapy, which was considered to be a natural phenomenon and a systemic reaction to the client's initial change. [47]. We propose the trend of progress and relapse as another unique systemic CFs that should be researched within a systemic perspective. That is, a change in one part/member of the system followed with changes in other parts as well as with support or reaction from neighboring systems [34, 45]. Systemic terminology (such as "symptom exchange," "change back," "social dominant narratives," "ecological model," etc.) can explain the trend of progress and relapse within a relational-contextual lens, which provides more therapeutic options and resources [56, 57]. We believe this common factor represents a unique systemic theme that could contribute to the understanding of change in relational therapy.

As a result of the therapist's effort to get the client system engaged in a task (functional pattern), the client system may react by "split systemic alliance" in which a part of the system experiences weaker alliance and so lower cooperation and engagement in the therapeutic task. Previous research [22, 48] indicates that the nature of alliance in family therapy is different than in individual therapy, due to the complex multiple relationships and competitive demands between the participants [35, 44]. We assume a systemic task asks for redefinition of relationships, power, and positions within the client system, which requires degrees of flexibility and responsibility by the members [47]. Also, it is consistent with the basic systemic assumption of triangulation. This is when a dyad that is not ready to take responsibility in a challenging situation drags the third person into their argument. This third person is often asked to "take sides" [35, 45]. Considering the critical role of systemic alliance in relational therapy outcome and dropout, it is important to explore what mechanisms are used by clinicians across treatment models to handle this challenge and which ones are more effective.

The main goal in the termination stage was to enable the client system to "maintain the achieved goals." The experts applied a few mechanisms to accomplish this goal: first, they used "attribution of success" in which the therapist uses a feedback loop and strengths-based conversation by which the client system explains how they made therapeutic changes. We assume this is consistent mostly with narrative and solution-focused questioning. Telling and re-telling the change a story of success enhances "self-efficacy" and "resiliency" in the client system [52, 58]. Second, they used "inoculation of future relapse" to educate the client system on useful strategies for handling any possible relapses following termination, which is mostly consistent with cognitive theory; third, they "expanded therapeutic alliance" and therapist availability for after termination in case the client system needed help, which generates hope, safety, and resiliency. This mechanism is most closely associated with attachment theory. We assume that integrative therapists apply a combination of these mechanisms that go beyond a specific theoretical model [5, 21]. Previous research [8] indicates that the therapy structure/plan itself contributes to therapy outcome. However, it is specifically important to explore when (if at all) and how clinicians address the termination process with their clients in daily practice. Moreover, what is its impact on therapy length and outcome? We assume this is an important component in the development of a temporal protocol for the use of common factors.

Consistent with other phased-based therapy proposals (e.g., [39, 40]), our findings indicate that common factors function within a phased-based framework. That is, the CFs are used as change mechanisms/strategies with specific proximal process goals at each stage of therapy, not as a list of distinct factors. This primarily temporal protocol of CFs can be used by trainers and trainees as a guide to map the sequence of actions in the course of therapy. Though, there are differences at the theoretical level (e.g., assumption of pathology, importance of relationships versus

**17**

the change process.

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

meaning, etc.) between traditional and post-modern MFT models, both emphasize the same phase-based goals and challenges; which are addressed through almost the same change mechanisms. For example, let aside that it is inconsistent with its collaborative philosophy, Solution-Focused Therapy (SFT) concerns with the clients' motivation level, and labeled them as visitors, complainants, and customers [59]. To solve such a cognitive dissonance at theoretical level, the SFT theorists intended that "the labels were not included; and the descriptions were more nuanced in later years," however, it did not change their actual practice in which they are applying almost the same strategies "normalizations, reframes, new information; and acknowledgment of clients' feelings" to improve the client's motivation level ([32], p. 69, 70). We believe that the field needs to redirect the focus of research and training on these phased-based change mechanisms, which can lead to better clinically relevant and theoretically integrative models [4, 5, 8]. As Kazdin [4] notes, "after decades of psychotherapy research, we cannot provide an evidence-based explanation for how or why even our most well-studied interventions produce change, that

is, the mechanism(s) through which treatments operate" (p 1).

important mediating factor between engagement and outcome.

Also, our findings indicate that each change mechanism may have a different function at different points of time in therapy process [37]. For example, a relational definition of the problem and/or the therapist's expertise initially are utilized to build hope and motivation, while the same mechanisms are utilized to repair split systemic alliance in the intermediate stage. So, we assume a cyclical/ recurring pattern of presence for these change mechanisms, not necessarily a linear one. For example, research [23] indicates that the client's engagement is the single best predictor of outcome. However, the therapeutic relationship may be the most

Based on systemic epistemology that is the core theoretical belief in all MFT models, our findings support the notion that CFs function differently in systemic/ relational therapy than individual therapy. As Bateson [34] mentioned "When you separate mind from the structure in which it is immanent, such as human relationships… you embark on a fundamental error," (p. 493). It seems, the pioneers (Bowen, Haley, Whitaker, Fisch, etc.) focused much more on shared underlying family/systemic processes and the relevant systemic change mechanisms than the specific models. This may have contributed in the field to be naturally short-term and integrative, specifically in actual practice [5]. Research supports the notion that CFs should be understood based on systemic concepts and interactional processes when it comes to relational therapies [7, 8, 10]. For example, Functional Family Therapy researchers found that high individual alliance by the adolescent is a predictor of dropout if there is unbalance in adolescent and parents' alliances with therapist [48]. On the other hand, postmodern theories also gradually admitted the power and complexity of dysfunctional patterns in some systems. Lipchik [32], as one of the pioneers of SFT, mentioned that the SFT team gradually modified their theoretical belief that the solution-focused process works, regardless of the type of problem or situation, and so recognized the complexities of some problems and the surrounding systems. Therefore, it is reasonable to assume that all effective MFT models (including traditional, postmodern, or integrative) deal with the same underlying systemic/ interactional processes in actual practice, regardless of their level of theoretical congruency and technical terminology. That is, the clinical research should focus on those change mechanisms (e.g., inoculation, systemic alliance, relational conceptualization, etc.) that can alter such systemic processes (e.g., split systemic alliance, lack of boundaries, etc.) which are common, in some degree, within all clinical problems. So, we need mechanism-based change theories and research that guide us regarding what mechanism to use, when to use it, and how it should be used during

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

#### *A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

meaning, etc.) between traditional and post-modern MFT models, both emphasize the same phase-based goals and challenges; which are addressed through almost the same change mechanisms. For example, let aside that it is inconsistent with its collaborative philosophy, Solution-Focused Therapy (SFT) concerns with the clients' motivation level, and labeled them as visitors, complainants, and customers [59]. To solve such a cognitive dissonance at theoretical level, the SFT theorists intended that "the labels were not included; and the descriptions were more nuanced in later years," however, it did not change their actual practice in which they are applying almost the same strategies "normalizations, reframes, new information; and acknowledgment of clients' feelings" to improve the client's motivation level ([32], p. 69, 70). We believe that the field needs to redirect the focus of research and training on these phased-based change mechanisms, which can lead to better clinically relevant and theoretically integrative models [4, 5, 8]. As Kazdin [4] notes, "after decades of psychotherapy research, we cannot provide an evidence-based explanation for how or why even our most well-studied interventions produce change, that is, the mechanism(s) through which treatments operate" (p 1).

Also, our findings indicate that each change mechanism may have a different function at different points of time in therapy process [37]. For example, a relational definition of the problem and/or the therapist's expertise initially are utilized to build hope and motivation, while the same mechanisms are utilized to repair split systemic alliance in the intermediate stage. So, we assume a cyclical/ recurring pattern of presence for these change mechanisms, not necessarily a linear one. For example, research [23] indicates that the client's engagement is the single best predictor of outcome. However, the therapeutic relationship may be the most important mediating factor between engagement and outcome.

Based on systemic epistemology that is the core theoretical belief in all MFT models, our findings support the notion that CFs function differently in systemic/ relational therapy than individual therapy. As Bateson [34] mentioned "When you separate mind from the structure in which it is immanent, such as human relationships… you embark on a fundamental error," (p. 493). It seems, the pioneers (Bowen, Haley, Whitaker, Fisch, etc.) focused much more on shared underlying family/systemic processes and the relevant systemic change mechanisms than the specific models. This may have contributed in the field to be naturally short-term and integrative, specifically in actual practice [5]. Research supports the notion that CFs should be understood based on systemic concepts and interactional processes when it comes to relational therapies [7, 8, 10]. For example, Functional Family Therapy researchers found that high individual alliance by the adolescent is a predictor of dropout if there is unbalance in adolescent and parents' alliances with therapist [48]. On the other hand, postmodern theories also gradually admitted the power and complexity of dysfunctional patterns in some systems. Lipchik [32], as one of the pioneers of SFT, mentioned that the SFT team gradually modified their theoretical belief that the solution-focused process works, regardless of the type of problem or situation, and so recognized the complexities of some problems and the surrounding systems.

Therefore, it is reasonable to assume that all effective MFT models (including traditional, postmodern, or integrative) deal with the same underlying systemic/ interactional processes in actual practice, regardless of their level of theoretical congruency and technical terminology. That is, the clinical research should focus on those change mechanisms (e.g., inoculation, systemic alliance, relational conceptualization, etc.) that can alter such systemic processes (e.g., split systemic alliance, lack of boundaries, etc.) which are common, in some degree, within all clinical problems. So, we need mechanism-based change theories and research that guide us regarding what mechanism to use, when to use it, and how it should be used during the change process.

*Family Therapy - New Intervention Programs and Researches*

this challenge and which ones are more effective.

Another important finding was a "trend of progress and relapse" in the second phase of therapy, which was considered to be a natural phenomenon and a systemic reaction to the client's initial change. [47]. We propose the trend of progress and relapse as another unique systemic CFs that should be researched within a systemic perspective. That is, a change in one part/member of the system followed with changes in other parts as well as with support or reaction from neighboring systems [34, 45]. Systemic terminology (such as "symptom exchange," "change back," "social dominant narratives," "ecological model," etc.) can explain the trend of progress and relapse within a relational-contextual lens, which provides more therapeutic options and resources [56, 57]. We believe this common factor represents a unique systemic theme that could contribute to the understanding of change in relational therapy. As a result of the therapist's effort to get the client system engaged in a task (functional pattern), the client system may react by "split systemic alliance" in which a part of the system experiences weaker alliance and so lower cooperation and engagement in the therapeutic task. Previous research [22, 48] indicates that the nature of alliance in family therapy is different than in individual therapy, due to the complex multiple relationships and competitive demands between the participants [35, 44]. We assume a systemic task asks for redefinition of relationships, power, and positions within the client system, which requires degrees of flexibility and responsibility by the members [47]. Also, it is consistent with the basic systemic assumption of triangulation. This is when a dyad that is not ready to take responsibility in a challenging situation drags the third person into their argument. This third person is often asked to "take sides" [35, 45]. Considering the critical role of systemic alliance in relational therapy outcome and dropout, it is important to explore what mechanisms are used by clinicians across treatment models to handle

The main goal in the termination stage was to enable the client system to "maintain the achieved goals." The experts applied a few mechanisms to accomplish this goal: first, they used "attribution of success" in which the therapist uses a feedback loop and strengths-based conversation by which the client system explains how they made therapeutic changes. We assume this is consistent mostly with narrative and solution-focused questioning. Telling and re-telling the change a story of success enhances "self-efficacy" and "resiliency" in the client system [52, 58]. Second, they used "inoculation of future relapse" to educate the client system on useful strategies for handling any possible relapses following termination, which is mostly consistent with cognitive theory; third, they "expanded therapeutic alliance" and therapist availability for after termination in case the client system needed help, which generates hope, safety, and resiliency. This mechanism is most closely associated with attachment theory. We assume that integrative therapists apply a combination of

these mechanisms that go beyond a specific theoretical model [5, 21].

Previous research [8] indicates that the therapy structure/plan itself contributes to therapy outcome. However, it is specifically important to explore when (if at all) and how clinicians address the termination process with their clients in daily practice. Moreover, what is its impact on therapy length and outcome? We assume this is an important component in the development of a temporal protocol for the

Consistent with other phased-based therapy proposals (e.g., [39, 40]), our findings indicate that common factors function within a phased-based framework. That is, the CFs are used as change mechanisms/strategies with specific proximal process goals at each stage of therapy, not as a list of distinct factors. This primarily temporal protocol of CFs can be used by trainers and trainees as a guide to map the sequence of actions in the course of therapy. Though, there are differences at the theoretical level (e.g., assumption of pathology, importance of relationships versus

**16**

use of common factors.

#### *Family Therapy - New Intervention Programs and Researches*

To that end, process-progress research [37] can help, since it explains the therapist and the client's actions at each point of the change process. Therefore, we can link in-session improvements on critical factors and treatment outcomes [11]. Accordingly, the "practice-based evidence" that is based on client's feedback can inform us about the client's theory of change [23]. Finally, the convergence of the therapist and the client's theories of change will provide useful evidence-based explanations for why and how therapy works, and through what mechanisms. We believe that the chronology of common factors that we present in this paper represents one important step in this direction.

### **Author details**

Hassan Karimi1 \*, Fred Piercy2 and Jyoti Savla2

1 Johns Hopkins University, Baltimore, USA

2 Virginia Tech, Blacksburg, VA, USA

\*Address all correspondence to: hassan.karimi@jhu.edu

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**19**

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

evidence. Annual Review of Psychology.

Journal of Marital and Family Therapy.

[11] Pinsof WM, Wynne LC. Toward progress research: Closing the gap between family therapy practice and research. Journal of Marital and Family

[12] Rosenzweig S. Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry. 1936;**6**(3):412-415

[13] Frank JD. Persuasion and Healing: A Comparative Study of Psychotherapy. Baltimore: Johns Hopkins University

[10] Sexton TL, Ridley CR, Kleiner AJ. Beyond common factors: Multilevelprocess models of therapeutic change in marriage and family therapy.

2001;**52**(1):685-716

2004;**30**(2):131-149

Therapy. 2000;**26**(1):1-8

[14] Luborsky L, Singer B, Luborsky L. Comparative studies of psychotherapies: Is it true that everyone has won and all must have prizes? Archives of General Psychiatry.

[15] Lambert MJ. Psychotherapy outcome research: Implications for integrative and eclectical therapists. In: Norcross JC, Goldfried MR, editors. Handbook of Psychotherapy Integration. New York: Oxford

[16] Karimi H. The contribution of common factors to therapeutic outcomes from the clinician's perspective: A mixed method study to explore common mechanisms of change [Doctoral dissertation].

[17] Grencavage LM, Norcross JC. Where are the commonalities among

University Press Basic; 1992. pp. 94-129

1975;**32**(8):995-1008

Virginia Tech; 2015

Press; 1961

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

[1] Shadish WR, Baldwin SA. Metaanalysis of MFT interventions. Journal of Marital and Family Therapy.

[2] Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral

therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA.

[3] Wampold BE. The Basics of

Psychological Association; 2010

[4] Kazdin AE. Mediators and

[6] Eysenck HJ. The effects of

Basic Books; 1961. pp. 697-725

2007;**33**(3):318-343

Psychology. 2007;**3**:1-27

Psychotherapy: An Introduction to Theory and Practice. : Washington Dc: American

mechanisms of change in psychotherapy research. Annual Review of Clinical

[5] Lebow J. Integrative approaches to couple and family therapy. In: Sexton TL, Weeks GR, Robbins MS, editors. Handbook of Family Therapy. New York, NY: Brunner Routledge; 2015. pp. 219-242

psychotherapy. In: Eysenck HJ, editor. Handbook of Abnormal Psychology: An Experimental Approach. New York:

[7] Davis SD, Piercy FP. What clients of couple therapy model developers and their former students say about change, part I: Model-dependent common factors across three models. Journal of Marital and Family Therapy.

[8] Sprenkle DH, Davis SD, Lebow JL. Common Factors in Couple and Family Therapy: The Overlooked Foundation for Effective Practice. New York, NY: The Guilford Press; 2009

[9] Chambless DL, Ollendick TH. Empirically supported psychological interventions: Controversies and

2000;**283**(19):2529-2536

**References**

2003;**29**(4):547-570

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

#### **References**

*Family Therapy - New Intervention Programs and Researches*

sents one important step in this direction.

To that end, process-progress research [37] can help, since it explains the therapist and the client's actions at each point of the change process. Therefore, we can link in-session improvements on critical factors and treatment outcomes [11]. Accordingly, the "practice-based evidence" that is based on client's feedback can inform us about the client's theory of change [23]. Finally, the convergence of the therapist and the client's theories of change will provide useful evidence-based explanations for why and how therapy works, and through what mechanisms. We believe that the chronology of common factors that we present in this paper repre-

**18**

**Author details**

Hassan Karimi1

provided the original work is properly cited.

\*, Fred Piercy2

1 Johns Hopkins University, Baltimore, USA

\*Address all correspondence to: hassan.karimi@jhu.edu

2 Virginia Tech, Blacksburg, VA, USA

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

and Jyoti Savla2

[1] Shadish WR, Baldwin SA. Metaanalysis of MFT interventions. Journal of Marital and Family Therapy. 2003;**29**(4):547-570

[2] Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA. 2000;**283**(19):2529-2536

[3] Wampold BE. The Basics of Psychotherapy: An Introduction to Theory and Practice. : Washington Dc: American Psychological Association; 2010

[4] Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology. 2007;**3**:1-27

[5] Lebow J. Integrative approaches to couple and family therapy. In: Sexton TL, Weeks GR, Robbins MS, editors. Handbook of Family Therapy. New York, NY: Brunner Routledge; 2015. pp. 219-242

[6] Eysenck HJ. The effects of psychotherapy. In: Eysenck HJ, editor. Handbook of Abnormal Psychology: An Experimental Approach. New York: Basic Books; 1961. pp. 697-725

[7] Davis SD, Piercy FP. What clients of couple therapy model developers and their former students say about change, part I: Model-dependent common factors across three models. Journal of Marital and Family Therapy. 2007;**33**(3):318-343

[8] Sprenkle DH, Davis SD, Lebow JL. Common Factors in Couple and Family Therapy: The Overlooked Foundation for Effective Practice. New York, NY: The Guilford Press; 2009

[9] Chambless DL, Ollendick TH. Empirically supported psychological interventions: Controversies and

evidence. Annual Review of Psychology. 2001;**52**(1):685-716

[10] Sexton TL, Ridley CR, Kleiner AJ. Beyond common factors: Multilevelprocess models of therapeutic change in marriage and family therapy. Journal of Marital and Family Therapy. 2004;**30**(2):131-149

[11] Pinsof WM, Wynne LC. Toward progress research: Closing the gap between family therapy practice and research. Journal of Marital and Family Therapy. 2000;**26**(1):1-8

[12] Rosenzweig S. Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry. 1936;**6**(3):412-415

[13] Frank JD. Persuasion and Healing: A Comparative Study of Psychotherapy. Baltimore: Johns Hopkins University Press; 1961

[14] Luborsky L, Singer B, Luborsky L. Comparative studies of psychotherapies: Is it true that everyone has won and all must have prizes? Archives of General Psychiatry. 1975;**32**(8):995-1008

[15] Lambert MJ. Psychotherapy outcome research: Implications for integrative and eclectical therapists. In: Norcross JC, Goldfried MR, editors. Handbook of Psychotherapy Integration. New York: Oxford University Press Basic; 1992. pp. 94-129

[16] Karimi H. The contribution of common factors to therapeutic outcomes from the clinician's perspective: A mixed method study to explore common mechanisms of change [Doctoral dissertation]. Virginia Tech; 2015

[17] Grencavage LM, Norcross JC. Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice. 1990;**21**(5):372

[18] Goldfried MR, Padawer W. Current status and future directions in psychotherapy. In: Converging Themes in Psychotherapy. New York, NY: Springer Publishing Company; 1982. pp. 3-49

[19] Gurman AS, Kniskern DP. The future of marital and family therapy. Psychotherapy: Theory, Research, Practice, Training. 1992;**29**(1):65

[20] Karasu TB. The specificity versus nonspecificity dilemma: Toward identifying therapeutic change agents. The American Journal of Psychiatry. 1986;**143**(6):687-695

[21] Prochaska JO, Norcross JC. Systems of Psychotherapy: A Transtheoretical Analysis. Belmont, CA: Thompson Brook/Cole; 2007

[22] Sprenkle DH, Blow AJ. Common factors are not islands—They work through models: A response to Sexton, Ridley, and Kleiner. Journal of Marital and Family Therapy. 2004;**30**(2):151-157

[23] Duncan BL, Miller SD, Sparks JA. Interactional and solution-focused brief therapies: Evolving concepts of change. In: Sexton TL, Weeks GR, Robbins MS, editors. Handbook of Family Therapy. New York, NY: Brunner Routledge: 2003. pp. 101-124

[24] Erickson MH. Special techniques of brief hypnotherapy. International Journal of Clinical and Experimental Hypnosis. 1954;**2**(2):109-129

[25] Blatt SJ, Sanislow CA III, Zuroff DC, Pilkonis PA. Characteristics of effective therapists: Further analyses of data from the National Institute of Mental Health treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology. 1996;**64**(6):1276

[26] Tallman K, Bohart AC. The client as a common factor: Clients as self-healers. In: Hubble MA, Duncan BL, Miller SD, editors. The Heart and Soul of Change: What Works in Therapy. Washington, DC: American Psychological Association; 1999. pp. 91-132

[27] Miller SD, Duncan BL, Hubble MA. Escape from babel: Toward a unifying language for psychotherapy practice. Adolescence. 1997;**32**(125):247

[28] Garfield SL. Brief psychotherapy: The role of common and specific factors. Clinical Psychology & Psychotherapy. 1997;**4**(4):217-225

[29] Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice. 1979;**16**(3):252

[30] Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology. 2000;**68**(3):438

[31] Friedlander ML, Escudero V, Heatherington L, Diamond GM. Alliance in couple and family therapy. Psychotherapy. 2011;**48**(1):25

[32] Lipchik E. The development of my personal solution-focused working model: From 1978 and continuing. International Journal of Solution-Focused Practices. 2014;**2**(2):63-73

[33] Robbins MS, Alexander JF, Turner CW. Disrupting defensive family interactions in family therapy with delinquent adolescents. Journal of Family Psychology. 2000;**14**(4):688

[34] Bateson G. The Logical Categories of Learning and Communication. Steps to an Ecology of Mind. Chicago: University of Chicago Press; 1972. pp. 279-308

**21**

pp. 164-191

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy*

[45] Minuchin S. Families and Family Therapy. Cambridge, MA: Harvard

[46] White M. Maps of Narrative Practice. New York, NY: WW Norton &

[47] Alexander JF, Robbins MS, Sexton TL. Family-based interventions with older, at-risk youth: From promise to proof to practice. Journal of Primary Prevention. 2000;**21**(2):185-205

[48] Robbins MS, Turner CW, Alexander JF, Perez GA. Alliance and dropout in family therapy for adolescents with behavior problems: Individual and systemic effects. Journal of Family

[49] Henggeler SW, Lee T. Multisystemic treatment of serious clinical problems. In: Kazdin AE, Weisz JR (Eds.), Evidence-based psychotherapies for children and adolescents. New York, NY: The Guilford Press; 2003. pp. 301-322

[50] Furrow JL, Edwards SA, Choi Y, Bradley B. Therapist presence in emotionally focused couple therapy blamer softening events: Promoting change through emotional experience. Journal of Marital and Family Therapy.

[51] Bandura A. Human agency in social cognitive theory. American Psychologist. 1989;**44**(9):1175

[52] Weinberger J. Common Factors are Not So Common and Specific Factors are Not So Specified: Toward an Inclusive Integration of Psychotherapy Research.

[53] Shapiro DA. Comparative credibility of treatment rationales: Three tests of expectancy theory. British Journal of Clinical Psychology. 1981;**20**(2):111-122

[54] Muir JA, Schwartz SJ, Szapocznik J. A program of research with Hispanic

2012;**38**:39-49

2014;**51**:514-518

Psychology. 2003;**17**(4):534

University Press; 1974

Company; 2007

*DOI: http://dx.doi.org/10.5772/intechopen.85357*

[35] Bowen M. Family Therapy in Clinical Practice. Lanhan, MD: Jason

[36] Kazdin AE. Treatment research: The investigation and evaluation of psychotherapy. In: Hersen ME, Kazdin AE, Bellack AS, editors. The Clinical Psychology Handbook. Elmsford, NY, US: Pergamon Press; 1991. pp. 293-312

[37] Bradley B, Johnson SM. Task Analysis of Couple and Family Change Events. Research Methods in Family Therapy. New York, NY: Guilford Press;

[38] Creswell JW, Hanson WE, Clark Plano VL, Morales A. Qualitative research designs: Selection and implementation. The Counseling Psychologist. 2007;**35**(2):236-264

[39] Prochaska JO, Norcross JC. Stages of change. Psychotherapy: Theory, Research, Practice, Training.

[40] Tracey TJ, Ray PB. Stages of successful time-limited counseling: An interactional examination. Journal of Counseling Psychology. 1984;**31**(1):13

[41] Castaños C, Piercy FP. The wiki as a virtual space for qualitative data collection. The Qualitative Report.

[42] Braun V, Clarke V. Thematic analysis. In: Cooper H, editor. The Handbook of Research Methods in Psychology. Washington, DC: American

Psychological Association; 2012

family therapy for externalizing disorders in adolescents. In: Handbook of Clinical Family Therapy. Hoboken,

NJ: John Wiley & Sons; 2005.

[43] Sexton TL, Alexander JF. Functional

[44] Haley J. Problem-Solving Therapy. San Francisco, CA: Jossey-Bass; 1987

Aronson; 1985

2005. pp. 254-271

2001;**38**(4):443

2010;**15**(4):948-955

*A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy DOI: http://dx.doi.org/10.5772/intechopen.85357*

[35] Bowen M. Family Therapy in Clinical Practice. Lanhan, MD: Jason Aronson; 1985

*Family Therapy - New Intervention Programs and Researches*

[26] Tallman K, Bohart AC. The client as a common factor: Clients as self-healers. In: Hubble MA, Duncan BL, Miller SD, editors. The Heart and Soul of Change: What Works in Therapy. Washington,

DC: American Psychological Association; 1999. pp. 91-132

[27] Miller SD, Duncan BL, Hubble MA. Escape from babel: Toward a unifying language for psychotherapy practice. Adolescence. 1997;**32**(125):247

[28] Garfield SL. Brief psychotherapy: The role of common and specific factors. Clinical Psychology & Psychotherapy. 1997;**4**(4):217-225

[29] Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice.

[30] Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology.

[31] Friedlander ML, Escudero V, Heatherington L, Diamond GM. Alliance in couple and family therapy.

[32] Lipchik E. The development of my personal solution-focused working model: From 1978 and continuing. International Journal of Solution-Focused Practices. 2014;**2**(2):63-73

[33] Robbins MS, Alexander JF, Turner CW. Disrupting defensive family interactions in family therapy with delinquent adolescents. Journal of Family Psychology. 2000;**14**(4):688

[34] Bateson G. The Logical Categories of Learning and Communication. Steps to an Ecology of Mind. Chicago: University of Chicago Press; 1972.

Psychotherapy. 2011;**48**(1):25

1979;**16**(3):252

2000;**68**(3):438

pp. 279-308

the therapeutic common factors? Professional Psychology: Research and

[18] Goldfried MR, Padawer W. Current

psychotherapy. In: Converging Themes in Psychotherapy. New York, NY: Springer Publishing Company; 1982. pp. 3-49

[19] Gurman AS, Kniskern DP. The future of marital and family therapy. Psychotherapy: Theory, Research, Practice, Training. 1992;**29**(1):65

[20] Karasu TB. The specificity versus nonspecificity dilemma: Toward identifying therapeutic change agents. The American Journal of Psychiatry.

[21] Prochaska JO, Norcross JC. Systems of Psychotherapy: A Transtheoretical Analysis. Belmont, CA: Thompson

[22] Sprenkle DH, Blow AJ. Common factors are not islands—They work through models: A response to Sexton, Ridley, and Kleiner. Journal of Marital and Family Therapy. 2004;**30**(2):151-157

[23] Duncan BL, Miller SD, Sparks JA. Interactional and solution-focused brief therapies: Evolving concepts of change. In: Sexton TL, Weeks GR, Robbins MS, editors. Handbook of Family Therapy. New York, NY: Brunner

Routledge: 2003. pp. 101-124

Hypnosis. 1954;**2**(2):109-129

[24] Erickson MH. Special techniques of brief hypnotherapy. International Journal of Clinical and Experimental

[25] Blatt SJ, Sanislow CA III, Zuroff DC, Pilkonis PA. Characteristics of effective therapists: Further analyses of data from the National Institute of Mental Health treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology.

1986;**143**(6):687-695

Brook/Cole; 2007

Practice. 1990;**21**(5):372

status and future directions in

**20**

1996;**64**(6):1276

[36] Kazdin AE. Treatment research: The investigation and evaluation of psychotherapy. In: Hersen ME, Kazdin AE, Bellack AS, editors. The Clinical Psychology Handbook. Elmsford, NY, US: Pergamon Press; 1991. pp. 293-312

[37] Bradley B, Johnson SM. Task Analysis of Couple and Family Change Events. Research Methods in Family Therapy. New York, NY: Guilford Press; 2005. pp. 254-271

[38] Creswell JW, Hanson WE, Clark Plano VL, Morales A. Qualitative research designs: Selection and implementation. The Counseling Psychologist. 2007;**35**(2):236-264

[39] Prochaska JO, Norcross JC. Stages of change. Psychotherapy: Theory, Research, Practice, Training. 2001;**38**(4):443

[40] Tracey TJ, Ray PB. Stages of successful time-limited counseling: An interactional examination. Journal of Counseling Psychology. 1984;**31**(1):13

[41] Castaños C, Piercy FP. The wiki as a virtual space for qualitative data collection. The Qualitative Report. 2010;**15**(4):948-955

[42] Braun V, Clarke V. Thematic analysis. In: Cooper H, editor. The Handbook of Research Methods in Psychology. Washington, DC: American Psychological Association; 2012

[43] Sexton TL, Alexander JF. Functional family therapy for externalizing disorders in adolescents. In: Handbook of Clinical Family Therapy. Hoboken, NJ: John Wiley & Sons; 2005. pp. 164-191

[44] Haley J. Problem-Solving Therapy. San Francisco, CA: Jossey-Bass; 1987

[45] Minuchin S. Families and Family Therapy. Cambridge, MA: Harvard University Press; 1974

[46] White M. Maps of Narrative Practice. New York, NY: WW Norton & Company; 2007

[47] Alexander JF, Robbins MS, Sexton TL. Family-based interventions with older, at-risk youth: From promise to proof to practice. Journal of Primary Prevention. 2000;**21**(2):185-205

[48] Robbins MS, Turner CW, Alexander JF, Perez GA. Alliance and dropout in family therapy for adolescents with behavior problems: Individual and systemic effects. Journal of Family Psychology. 2003;**17**(4):534

[49] Henggeler SW, Lee T. Multisystemic treatment of serious clinical problems. In: Kazdin AE, Weisz JR (Eds.), Evidence-based psychotherapies for children and adolescents. New York, NY: The Guilford Press; 2003. pp. 301-322

[50] Furrow JL, Edwards SA, Choi Y, Bradley B. Therapist presence in emotionally focused couple therapy blamer softening events: Promoting change through emotional experience. Journal of Marital and Family Therapy. 2012;**38**:39-49

[51] Bandura A. Human agency in social cognitive theory. American Psychologist. 1989;**44**(9):1175

[52] Weinberger J. Common Factors are Not So Common and Specific Factors are Not So Specified: Toward an Inclusive Integration of Psychotherapy Research. 2014;**51**:514-518

[53] Shapiro DA. Comparative credibility of treatment rationales: Three tests of expectancy theory. British Journal of Clinical Psychology. 1981;**20**(2):111-122

[54] Muir JA, Schwartz SJ, Szapocznik J. A program of research with Hispanic and African American families: Three decades of intervention development and testing influenced by the changing cultural context of Miami. Journal of Marital and Family Therapy. 2004;**30**(3):285-303

[55] Chen R, Piercy FP, Huang WJ, Jaramillo-Sierra AL, Karimi H, Chang WN, et al. A cross-National Study of therapists' perceptions and experiences of premature dropout from therapy. Journal of Family Psychotherapy. 2017;**28**(3):269-284

[56] Fishman HC, Andes F, Knowlton R. Enhancing family therapy: The addition of a community resource specialist. Journal of Marital and Family Therapy. 2001;**27**(1):111-116

[57] Liddle HA. Conceptual and clinical dimensions of a multidimensional, multisystems engagement strategy in family-based adolescent treatment. Psychotherapy: Theory, Research, Practice, Training. 1995;**32**(1):39

[58] Walsh F. Family resilience: A framework for clinical practice. Family Process. 2003;**42**(1):1-8

[59] De Shazer S. Patterns of Brief Family Therapy: An Ecosystemic Approach. New York, NY: The Guilford Press; 1982

**23**

**Chapter 2**

**Abstract**

tion and stability.

**1. Introduction**

attachment, negative interactions

*Katherine Stavrianopoulos*

Emotionally Focused Family

Therapy: Rebuilding Family Bonds

Relationships with parents, siblings, and other family members go through transitions as they move along the life cycle. Resilient families realign their relationships to respond to the changing demands and stressors within the family system. Those who are unable, find themselves in repetitive patterns marked by conflict and distress, often resulting in their need to seek treatment. Based on attachment theory, Emotionally Focused Family Therapy (EFFT) is a pragmatic short-term treatment approach designed to alleviate distress in family functioning. This chapter provides an overview of EFFT process, its theoretical underpinnings and the strategies EFT family therapists employ to promote positive outcomes. The presentation of a case study provides a unique lens where the therapist illustrates moment to moment interventions in an attempt to create new and more favorable family interactions, ones that enhance family members' feelings of attachment, empathy, communica-

**Keywords:** emotionally focused family therapy, family distress, adolescence,

In the last 20 years, research studies have demonstrated the effectiveness of emotionally focused couple therapy (EFT) in helping couples repair their distressed relationships. The natural extension and broader application of EFT couple's treatment can prove especially valuable and effective when working in a family system [1, 2]. The foundational principles of Emotionally Focused Couple's Therapy is based on attachment and bonding theories that aim to help individuals gain a greater awareness of their emotions, to provide them with strategies to effectively cope, regulate, and transform their emotions[3]. It is a short term, evidence-based approach that allows the therapist to set goals, target key processes, and chart a destination for couples to identify and remove those emotional blocks which derail the promotion of healthy functioning, while providing alternative approaches that serve to increase levels of attentiveness, empathy and feelings attachment and belonging with one another. According to Johnson, [4] EFFT is similar to emotionally focused therapy for couples, except that with families, the goal is "to modify family relationships in the direction of increased accessibility and responsiveness, thus helping the family create a secure base for children to grow and leave from." Working within a larger family system can be especially daunting as therapists attempt to navigate the vast landscape of family dynamics encompassing multiple, complex interpersonal processes between members, especially the powerful bonds that exist between parent

#### **Chapter 2**

*Family Therapy - New Intervention Programs and Researches*

and African American families: Three decades of intervention development and testing influenced by the changing cultural context of Miami. Journal of Marital and Family Therapy.

[55] Chen R, Piercy FP, Huang WJ, Jaramillo-Sierra AL, Karimi H, Chang WN, et al. A cross-National Study of therapists' perceptions and experiences of premature dropout from therapy. Journal of Family Psychotherapy.

[56] Fishman HC, Andes F, Knowlton R. Enhancing family therapy: The addition of a community resource specialist. Journal of Marital and Family

[57] Liddle HA. Conceptual and clinical dimensions of a multidimensional, multisystems engagement strategy in family-based adolescent treatment. Psychotherapy: Theory, Research, Practice, Training. 1995;**32**(1):39

[58] Walsh F. Family resilience: A framework for clinical practice. Family

[59] De Shazer S. Patterns of Brief Family Therapy: An Ecosystemic Approach. New York, NY: The Guilford

Process. 2003;**42**(1):1-8

Press; 1982

Therapy. 2001;**27**(1):111-116

2004;**30**(3):285-303

2017;**28**(3):269-284

**22**

## Emotionally Focused Family Therapy: Rebuilding Family Bonds

*Katherine Stavrianopoulos*

#### **Abstract**

Relationships with parents, siblings, and other family members go through transitions as they move along the life cycle. Resilient families realign their relationships to respond to the changing demands and stressors within the family system. Those who are unable, find themselves in repetitive patterns marked by conflict and distress, often resulting in their need to seek treatment. Based on attachment theory, Emotionally Focused Family Therapy (EFFT) is a pragmatic short-term treatment approach designed to alleviate distress in family functioning. This chapter provides an overview of EFFT process, its theoretical underpinnings and the strategies EFT family therapists employ to promote positive outcomes. The presentation of a case study provides a unique lens where the therapist illustrates moment to moment interventions in an attempt to create new and more favorable family interactions, ones that enhance family members' feelings of attachment, empathy, communication and stability.

**Keywords:** emotionally focused family therapy, family distress, adolescence, attachment, negative interactions

#### **1. Introduction**

In the last 20 years, research studies have demonstrated the effectiveness of emotionally focused couple therapy (EFT) in helping couples repair their distressed relationships. The natural extension and broader application of EFT couple's treatment can prove especially valuable and effective when working in a family system [1, 2]. The foundational principles of Emotionally Focused Couple's Therapy is based on attachment and bonding theories that aim to help individuals gain a greater awareness of their emotions, to provide them with strategies to effectively cope, regulate, and transform their emotions[3]. It is a short term, evidence-based approach that allows the therapist to set goals, target key processes, and chart a destination for couples to identify and remove those emotional blocks which derail the promotion of healthy functioning, while providing alternative approaches that serve to increase levels of attentiveness, empathy and feelings attachment and belonging with one another.

According to Johnson, [4] EFFT is similar to emotionally focused therapy for couples, except that with families, the goal is "to modify family relationships in the direction of increased accessibility and responsiveness, thus helping the family create a secure base for children to grow and leave from." Working within a larger family system can be especially daunting as therapists attempt to navigate the vast landscape of family dynamics encompassing multiple, complex interpersonal processes between members, especially the powerful bonds that exist between parent

and child, which when weak and broken—are often the root of familiar distress and dysfunction. The core of the human experience of a family lies within its ability to create supportive bonds that sustain it during turbulent and stressful times in its life cycle. The application of EFT to family treatment offers a practical, useful and expedient model from which to effectively bolster stronger and more empathic bonds between parents and their children.

This chapter provides an overview of EFFT process, its theoretical underpinnings and the strategies EFT family therapists employ to promote healthy family functioning. Through a presentation of a case study, beginning therapists are provided a unique lens from which to view the interactions of both family and therapist as they attempt to create new family interactions, marked by increased parental accessibility and responsiveness to children, which ultimately leads to their enhanced sense of attachment, communication, belongingness and security.

#### **2. Theoretical framework**

Emotionally Focused Family Therapy (EFFT) is an integration of humanistic [5] and systemic therapeutic approaches [6]. The focus of treatment is on the ongoing construction of a family's present experience and how patterns of interaction are organized and expressed between family members. Another significant aspect of EFFT is its detailed attention to emotions. Identifying emotions is viewed by the therapist as essential in how family members view themselves and others, or an event. Emotions are hard wired in our brain and are meant to inform us about our environment. They also, contain physical impulses, which are designed by nature to be an immediate and adaptive call to action. In EFFT, emotions are categorized as primary and secondary. Primary emotions have been identified by researchers as universal emotions, such as joy, anger, fear, sadness, surprise, and shame. These emotions are frequently outside of people's awareness. Secondary emotions are defined as reactions, and they help people cope with their primary emotions. The word "emotion" comes from the Latin word, *emovare* meaning "to move." Emotions are openly identified, shared and often reframed by the EFFT therapist, as a vehicle to help family members navigate into new and more favorable patterns of interaction, one's that are more empathic and capable of building safe and healthier relationships.

EFFT is grounded in attachment theory and based on the work of psychologist John Bowlby [7]. Bowlby maintains that human beings are biologically and fundamentally driven to pursue relationships that create security and belonging. He contends that the most critical attachment relationship is an infant's sense of protection created by the primary caregiver (typically the mother) through a series of reciprocal interactions which promote bonding and love. As Karen [8] in *Becoming Attached* says about love, "You don't need to be rich or smart or talented or funny; you just have to be there." A parent's emotionally engaged presence makes all the difference between disconnection and security. Throughout the cycle children and adolescents reach out to their primary attachment figures when they are in distress. If they experience parents as non- responsive or unavailable, it is natural for them to feel isolated, frightened and anxious. Feelings of insecurity in children are likely to heighten expressions that call for parental reassurance. Conversely, children may engage in behaviors that disengage and avoid their expressions of distress, particularly in moments of need [9–11]. In either scenario the resulting negative relational experiences foster instability and anxiety in the family system.

In EFFT, one's sense of a secure attachment is linked to positive mental health. Children who are securely attached are best able to turn to their attachment figures for comfort and support [12]. Mikulincer and Shaver [13] capture the distinction

**25**

attachment.

*Emotionally Focused Family Therapy: Rebuilding Family Bonds*

between these predictable patterns of attachment behavior as shown in their research when they describe the issues of secure vs. insecure scripts. The secure script is: "If I encounter an obstacle and/or become distressed, I can approach a significant other for help; he or she is likely to be available and supportive; I will experience relief and comfort as a result of proximity to this person; I can then return to other activities [13]." However, when the attachment system remains in an activated state, there are two different insecure coping responses. The avoidant (dismissive) approach "includes rapid self-protective responses to danger without examining one's emotions, consulting other people or seeking to receive help from them [13]." The implicit script is, "If I am in distress, I will carry on with other activities." In contrast, the anxious approach is described as always being on guard for threat, and having difficulty receiving comfort. The implicit script is, "If I am in distress, I will reach for you and reach for you and reach for you, endlessly and to no avail."

Attachment anxiety and avoidance are natural responses to the lack of confidence in the parents' emotional availability. Drawing from attachment theory, the EFFT therapist conceptualizes distress in terms of attachment dilemmas in which ineffective responses to attachment needs fuel miscommunication, creating parenting dysfunctions and exacerbating symptoms associated with individual psychopathology [14]. The therapist must obtain a clear understanding of symptoms that generate distress in the family and furthermore, evaluate the parent(s) availability and their children's confidence in their availability. These observations will provide the therapist with information about the attachment quality in the parent–child relationship. Insecure attachment is evident when the parent's capacity for empathy is blocked, giving precedence to feelings of anxiety and anger, thus viewing the child as difficult, antagonistic or uncooperative. In such instance, parents tend to blame the adolescent or child as solely the identified patient and remain oblivious to the underlying emotions, of fear, or sadness that are at play [15]. The EFFT therapist connects the child/adolescent's symptoms to their perception that the caregiver is unavailable and detached. This perception increases a child's anxiety, anger and defensiveness that contributes to the presenting problem [9, 16]. The goal of the EFFT therapist is to work through a series of interventions that reframe the family problem as one arising out of an attachment crisis, and subsequently works to normalize family difficulties without blaming anyone [17]. Key to the EFFT process

is understanding and integrating these core theoretical principals.

stages and steps of EFFT are outlined and discussed below.

Step 1: Forming an alliance and family assessment.

**3.1 Stage one: Deescalating family distress**

The process of EFFT is categorized into three stages and nine treatment steps. In the initial four treatment steps, the therapist carefully focuses on assessing the interactive styles of the family and judiciously works to deescalate any conflicts as they emerge. In the middle phases of treatment (steps five, six, and seven), the therapist and family, work in concert to find new ways to establish more secure familial relationships. In the final two steps of treatment, the therapist highlights and validates new patterns of positive interaction. As importantly, the therapist reinforces family members confidence to handle future conflicts and issues now that they are armed with greater empathy and understanding for one another. The

Step 2: Identifying negative interactional patterns that maintain insecure

**3. EFFT process: Steps and stages**

*DOI: http://dx.doi.org/10.5772/intechopen.84320*

#### *Emotionally Focused Family Therapy: Rebuilding Family Bonds DOI: http://dx.doi.org/10.5772/intechopen.84320*

*Family Therapy - New Intervention Programs and Researches*

bonds between parents and their children.

**2. Theoretical framework**

and child, which when weak and broken—are often the root of familiar distress and dysfunction. The core of the human experience of a family lies within its ability to create supportive bonds that sustain it during turbulent and stressful times in its life cycle. The application of EFT to family treatment offers a practical, useful and expedient model from which to effectively bolster stronger and more empathic

This chapter provides an overview of EFFT process, its theoretical underpinnings and the strategies EFT family therapists employ to promote healthy family functioning. Through a presentation of a case study, beginning therapists are provided a unique lens from which to view the interactions of both family and therapist as they attempt to create new family interactions, marked by increased parental accessibility and responsiveness to children, which ultimately leads to their

Emotionally Focused Family Therapy (EFFT) is an integration of humanistic [5] and systemic therapeutic approaches [6]. The focus of treatment is on the ongoing construction of a family's present experience and how patterns of interaction are organized and expressed between family members. Another significant aspect of EFFT is its detailed attention to emotions. Identifying emotions is viewed by the therapist as essential in how family members view themselves and others, or an event. Emotions are hard wired in our brain and are meant to inform us about our environment. They also, contain physical impulses, which are designed by nature to be an immediate and adaptive call to action. In EFFT, emotions are categorized as primary and secondary. Primary emotions have been identified by researchers as universal emotions, such as joy, anger, fear, sadness, surprise, and shame. These emotions are frequently outside of people's awareness. Secondary emotions are defined as reactions, and they help people cope with their primary emotions. The word "emotion" comes from the Latin word, *emovare* meaning "to move." Emotions are openly identified, shared and often reframed by the EFFT therapist, as a vehicle to help family members navigate into new and more favorable patterns of interaction, one's that are more empathic and capable of building safe and healthier relationships. EFFT is grounded in attachment theory and based on the work of psychologist John Bowlby [7]. Bowlby maintains that human beings are biologically and fundamentally driven to pursue relationships that create security and belonging. He contends that the most critical attachment relationship is an infant's sense of protection created by the primary caregiver (typically the mother) through a series of reciprocal interactions which promote bonding and love. As Karen [8] in *Becoming Attached* says about love, "You don't need to be rich or smart or talented or funny; you just have to be there." A parent's emotionally engaged presence makes all the difference between disconnection and security. Throughout the cycle children and adolescents reach out to their primary attachment figures when they are in distress. If they experience parents as non- responsive or unavailable, it is natural for them to feel isolated, frightened and anxious. Feelings of insecurity in children are likely to heighten expressions that call for parental reassurance. Conversely, children may engage in behaviors that disengage and avoid their expressions of distress, particularly in moments of need [9–11]. In either scenario the resulting negative relational

enhanced sense of attachment, communication, belongingness and security.

experiences foster instability and anxiety in the family system.

In EFFT, one's sense of a secure attachment is linked to positive mental health. Children who are securely attached are best able to turn to their attachment figures for comfort and support [12]. Mikulincer and Shaver [13] capture the distinction

**24**

between these predictable patterns of attachment behavior as shown in their research when they describe the issues of secure vs. insecure scripts. The secure script is: "If I encounter an obstacle and/or become distressed, I can approach a significant other for help; he or she is likely to be available and supportive; I will experience relief and comfort as a result of proximity to this person; I can then return to other activities [13]." However, when the attachment system remains in an activated state, there are two different insecure coping responses. The avoidant (dismissive) approach "includes rapid self-protective responses to danger without examining one's emotions, consulting other people or seeking to receive help from them [13]." The implicit script is, "If I am in distress, I will carry on with other activities." In contrast, the anxious approach is described as always being on guard for threat, and having difficulty receiving comfort. The implicit script is, "If I am in distress, I will reach for you and reach for you and reach for you, endlessly and to no avail."

Attachment anxiety and avoidance are natural responses to the lack of confidence in the parents' emotional availability. Drawing from attachment theory, the EFFT therapist conceptualizes distress in terms of attachment dilemmas in which ineffective responses to attachment needs fuel miscommunication, creating parenting dysfunctions and exacerbating symptoms associated with individual psychopathology [14]. The therapist must obtain a clear understanding of symptoms that generate distress in the family and furthermore, evaluate the parent(s) availability and their children's confidence in their availability. These observations will provide the therapist with information about the attachment quality in the parent–child relationship. Insecure attachment is evident when the parent's capacity for empathy is blocked, giving precedence to feelings of anxiety and anger, thus viewing the child as difficult, antagonistic or uncooperative. In such instance, parents tend to blame the adolescent or child as solely the identified patient and remain oblivious to the underlying emotions, of fear, or sadness that are at play [15]. The EFFT therapist connects the child/adolescent's symptoms to their perception that the caregiver is unavailable and detached. This perception increases a child's anxiety, anger and defensiveness that contributes to the presenting problem [9, 16]. The goal of the EFFT therapist is to work through a series of interventions that reframe the family problem as one arising out of an attachment crisis, and subsequently works to normalize family difficulties without blaming anyone [17]. Key to the EFFT process is understanding and integrating these core theoretical principals.

#### **3. EFFT process: Steps and stages**

The process of EFFT is categorized into three stages and nine treatment steps. In the initial four treatment steps, the therapist carefully focuses on assessing the interactive styles of the family and judiciously works to deescalate any conflicts as they emerge. In the middle phases of treatment (steps five, six, and seven), the therapist and family, work in concert to find new ways to establish more secure familial relationships. In the final two steps of treatment, the therapist highlights and validates new patterns of positive interaction. As importantly, the therapist reinforces family members confidence to handle future conflicts and issues now that they are armed with greater empathy and understanding for one another. The stages and steps of EFFT are outlined and discussed below.

#### **3.1 Stage one: Deescalating family distress**

Step 1: Forming an alliance and family assessment.

Step 2: Identifying negative interactional patterns that maintain insecure attachment.

Step 3: Accessing underlying emotions informing interactional positions/relational blocks.

Step 4: Reframing the problem in light of relational blocks and negative interaction patterns.

The primary focus in stage one is for the therapist to identify and track behaviors and secondary emotions that fuel attachment insecurities. The therapist guides the family away from focusing on the content of their presenting conflicts, to developing a more attentive awareness about what underlies their expressed difficulties. The therapist accomplishes this task by tracking familial behaviors driven by intense emotion. As therapists understand, in times of distress, family members commonly deal with their feelings and interpersonal behaviors in unproductive ways. Some may withdraw, argue, submit, explain, or engage in other behaviors designed to minimize and distract from their emotional pain. In this stage, the therapist pays close attention to the interactive behaviors of the family and reframes maladaptive or secondary emotional responses in efforts to bring into awareness their negative cycle of interactions. A negative cycle is defined as a predictable interactional pattern that gets repeated and organizes the family around insecurity, rather than vulnerability. Negative cycles are fatiguing and destructive for family functioning. Tracking the cycle interrupts the behavior and reveals for the first time to the family their true underlying emotions and how their current behaviors serve as protective mechanisms to avoid discomfort and pain. Accessing primary emotions such as fear, hurt, and sadness creates empathy among family members, facilitates responsiveness, and helps the family deescalate [18]. During this phase of treatment, the therapist often returns to utilizing tracking interventions to reemphasize to the family the importance of understanding and dealing with the underlying issues of their discontent in order to enhance family stability and healthy functioning.

#### **3.2 Stage two: Restructuring family interactions**

Step 5: Accessing and deepening a child's disowned aspects of self and attachment needs.

Step 6: Fostering acceptance of child's new experience and attachment related needs.

Step 7: Restructuring family interactions focusing on sharing attachment needs and supportive caregiving responses.

In stage two, the focus is on deepening and expanding primary emotions and unmet attachment needs, in order to reshape attachment bonds between family members that are more secure and connected. The change event in stage two involves the therapist accessing the needs embedded in the newly expanded primary emotions that drive the negative family cycle; and helping family members learn to identify and request that previously unexpressed core attachment needs be addressed. The therapist intentionally structures interventions known as enactments that function to restructure attachment bonds between family members [14]. Typically, these requests are for direct care, contact, or comfort and the shift is premised on the parent(s) ability to respond to their children's vulnerability. It is very common in this stage to observe parents having the desire to respond in a more emotionally connected way to their child, but their empathy may be restricted. In such instances, the EFFT therapist will work with the parents to develop their capacity and ability to respond in a way that shifts family relationships toward more secure bonds, replacing negative and harmful cycles of interactions.

**27**

*Emotionally Focused Family Therapy: Rebuilding Family Bonds*

Step 8: Exploring new solutions to past problems from more secure positions. Step 9: Consolidating new positions and strengthening positive patterns. Finally, in stage three of EFFT, positive cycles of bonding are consolidated and integrated into the life of the family. At the end of this stage, the family is best able to integrate new ways of engaging in discussions and investing in greater security [18]. Discussions are characterized by more openness, responsiveness, and engagement among family members. It is imperative for the family to learn how to repair failed attempts to connect outside of sessions. Before termination, the therapist affirms that the family is now able to handle its issues and conflicts by examining and resolving them in new and more effective ways. The therapist also focuses on amplifying the family's vision to include more mindfulness of positive affect,

There are two primary sets of interventions utilized by EFFT clinicians to help families navigate through the various stages of the treatment process. These core interventions are designed to direct families toward developing relational bonds that enhance their security, communication and strength. The first set are interventions for accessing, expanding and reprocessing of emotional experience. The

second set are interventions for restructuring the family interactions.

**4.1 Accessing, expanding and reprocessing emotional experience**

tion the reader is referred to the EFT manual [3].

deeper awareness of their emotional experiencing.

you become very critical with your son. Is that right?"

that you would feel this way, given (state specific context)".

The EFFT techniques used within these categories are described below, followed by an example of a therapist's response to highlight and reinforce a more concrete understanding of the techniques deployed. For a more detailed explana-

Reflect (name, order, or distill) emotional processing as it occurs. Slows down the process, directs and focuses attention inward, helps the therapist attune to the client experience, thus conveying understanding and helps in creating alliance. Empathic reflections need to be specific and vivid in order to move the client into a

Therapist: "I think I hear you say that you become so anxious about his future that you find yourself wanting to control, wanting to know what he has in mind because not knowing or not having 'a say' is so overwhelming. Is that it? And then

Conveys that the client is entitled to their experience. Such statements function to affirm, and legitimize, the client's experience as understandable, given the attachment relationship context. Validating statements start with, "it makes sense

Therapist*: "*That makes sense to me, that when you feel that things are about to escalate between you and your mom, you go away, and you avoid any conversation.

*DOI: http://dx.doi.org/10.5772/intechopen.84320*

**3.3. Stage three: Consolidation**

vulnerable reaching, and connection.

**4. Core interventions**

*4.1.1 Empathic reflection*

*4.1.2 Validation*

Is that right?"

#### **3.3. Stage three: Consolidation**

*Family Therapy - New Intervention Programs and Researches*

tional blocks.

tion patterns.

and healthy functioning.

ment needs.

needs.

**3.2 Stage two: Restructuring family interactions**

and supportive caregiving responses.

Step 3: Accessing underlying emotions informing interactional positions/rela-

Step 4: Reframing the problem in light of relational blocks and negative interac-

The primary focus in stage one is for the therapist to identify and track behav-

Step 5: Accessing and deepening a child's disowned aspects of self and attach-

Step 6: Fostering acceptance of child's new experience and attachment related

Step 7: Restructuring family interactions focusing on sharing attachment needs

In stage two, the focus is on deepening and expanding primary emotions and unmet attachment needs, in order to reshape attachment bonds between family members that are more secure and connected. The change event in stage two involves the therapist accessing the needs embedded in the newly expanded primary emotions that drive the negative family cycle; and helping family members learn to identify and request that previously unexpressed core attachment needs be addressed. The therapist intentionally structures interventions known as enactments that function to restructure attachment bonds between family members [14]. Typically, these requests are for direct care, contact, or comfort and the shift is premised on the parent(s) ability to respond to their children's vulnerability. It is very common in this stage to observe parents having the desire to respond in a more emotionally connected way to their child, but their empathy may be restricted. In such instances, the EFFT therapist will work with the parents to develop their capacity and ability to respond in a way that shifts family relationships toward more secure bonds, replacing negative and harmful cycles

iors and secondary emotions that fuel attachment insecurities. The therapist guides the family away from focusing on the content of their presenting conflicts, to developing a more attentive awareness about what underlies their expressed difficulties. The therapist accomplishes this task by tracking familial behaviors driven by intense emotion. As therapists understand, in times of distress, family members commonly deal with their feelings and interpersonal behaviors in unproductive ways. Some may withdraw, argue, submit, explain, or engage in other behaviors designed to minimize and distract from their emotional pain. In this stage, the therapist pays close attention to the interactive behaviors of the family and reframes maladaptive or secondary emotional responses in efforts to bring into awareness their negative cycle of interactions. A negative cycle is defined as a predictable interactional pattern that gets repeated and organizes the family around insecurity, rather than vulnerability. Negative cycles are fatiguing and destructive for family functioning. Tracking the cycle interrupts the behavior and reveals for the first time to the family their true underlying emotions and how their current behaviors serve as protective mechanisms to avoid discomfort and pain. Accessing primary emotions such as fear, hurt, and sadness creates empathy among family members, facilitates responsiveness, and helps the family deescalate [18]. During this phase of treatment, the therapist often returns to utilizing tracking interventions to reemphasize to the family the importance of understanding and dealing with the underlying issues of their discontent in order to enhance family stability

**26**

of interactions.

Step 8: Exploring new solutions to past problems from more secure positions. Step 9: Consolidating new positions and strengthening positive patterns.

Finally, in stage three of EFFT, positive cycles of bonding are consolidated and integrated into the life of the family. At the end of this stage, the family is best able to integrate new ways of engaging in discussions and investing in greater security [18]. Discussions are characterized by more openness, responsiveness, and engagement among family members. It is imperative for the family to learn how to repair failed attempts to connect outside of sessions. Before termination, the therapist affirms that the family is now able to handle its issues and conflicts by examining and resolving them in new and more effective ways. The therapist also focuses on amplifying the family's vision to include more mindfulness of positive affect, vulnerable reaching, and connection.

#### **4. Core interventions**

There are two primary sets of interventions utilized by EFFT clinicians to help families navigate through the various stages of the treatment process. These core interventions are designed to direct families toward developing relational bonds that enhance their security, communication and strength. The first set are interventions for accessing, expanding and reprocessing of emotional experience. The second set are interventions for restructuring the family interactions.

The EFFT techniques used within these categories are described below, followed by an example of a therapist's response to highlight and reinforce a more concrete understanding of the techniques deployed. For a more detailed explanation the reader is referred to the EFT manual [3].

#### **4.1 Accessing, expanding and reprocessing emotional experience**

#### *4.1.1 Empathic reflection*

Reflect (name, order, or distill) emotional processing as it occurs. Slows down the process, directs and focuses attention inward, helps the therapist attune to the client experience, thus conveying understanding and helps in creating alliance. Empathic reflections need to be specific and vivid in order to move the client into a deeper awareness of their emotional experiencing.

Therapist: "I think I hear you say that you become so anxious about his future that you find yourself wanting to control, wanting to know what he has in mind because not knowing or not having 'a say' is so overwhelming. Is that it? And then you become very critical with your son. Is that right?"

#### *4.1.2 Validation*

Conveys that the client is entitled to their experience. Such statements function to affirm, and legitimize, the client's experience as understandable, given the attachment relationship context. Validating statements start with, "it makes sense that you would feel this way, given (state specific context)".

Therapist*: "*That makes sense to me, that when you feel that things are about to escalate between you and your mom, you go away, and you avoid any conversation. Is that right?"

#### *4.1.3 Evocative responding*

Through the use of questions, evocative language, and metaphors the therapist opens up the client's experience and encourages them to take another step toward it

Therapist: "What's happening right now as you hear him say that?" "What's it like for you when she follows you around the house, pushing for your attention?"

#### *4.1.4 Heightening*

This intervention intensifies, clarifies, and deepens an emotion through persistent focus, reflection or enactments. Thus, allowing the client to identify and accept their emotional experience. The therapist's pacing, tone and timing are significant. The acronym RISSSC, implying emotional risk [3], represents how this intervention is done: with repetition, images, speaking simply, softly, slowly, and using client's words. The soft tone heightens vulnerability and sooths the dysregulated brain, so the client can process clearly.

Therapist: *"* This sounds really important, can we stay here for a bit, I think I hear you say that deep down you really go to a bad place, a place where you get the message that you are nothing but a failure in their eyes. A real disappointment for a son, and that makes you feel so sad, so hurt inside."

#### *4.1.5 Empathic conjecture*

Therapist offers an interpretation of client's experience, or a hunch seen through the attachment lens. This facilitates a more intense experiencing from which new meanings may arise and an expanded awareness. It is important to convey tentativeness when offering a conjecture and to check if what is communicated matches the client's experience.

Therapist*:* "As I listen to you, I hear you saying that you are angry about her lack of concern for you, but I see the tears in your eyes and I wonder if you are also saying that you are hurt by her lack of concern. Does that seem to fit?"

#### **4.2 Restructuring interventions**

The following interventions are used in EFFT to address the restructuring task:

#### *4.2.1 Tracking, and reflecting interactions*

Reflections that track family members behaviors slow down and clarify the interactional process.

Therapist: "So, when Alex gets frustrated and walks away ignoring what you say, you get angry too and follow him. You need him to listen to you. And, when your mom follows you around wanting your attention it makes you shut down even more."

#### *4.2.2 Reframing*

Reframing interactions in the context of the negative cycle, and attachment needs. An attachment reframe functions to access a positive meaning or intention for a seemingly negative response. It shifts the view of the member to a positive portrayal.

Therapist: "You don't experience that the louder she gets, the more desperately she is trying to find you. It sounds as if she is upset with you, but she is doing everything she can to get close to you."

**29**

*Emotionally Focused Family Therapy: Rebuilding Family Bonds*

The therapist requests direct sharing of a clearly distilled message from one family member to another. Enactments, the most powerful intervention in EFFT, their function is to heighten emotional experience and reshape new interactions among family members which lead to positive cycles of accessibility and responsiveness. Therapist: "Can you tell her, 'I go away because I don't want things to get worse

To help illustrate EFFT treatment in action, a case study of a family recently seen

The family is composed of James and Penny (names and identifying information have been altered), a professional couple in their early 50s, married for 28 years. They have two children; Ellie (23) and Alex (19). The couple has been on and off in couple therapy for a year. The presenting problem described by the parents focused on their son Alex, who had told them at the end of his third semester in college that he wanted to drop out because "this kind of education" was not for him, and he did not see how it would help him get a job. Both parents were very upset and after much discussion, hesitantly agreed to allow him to take a "gap year." It was their understanding that after the year break, Alex was to resume his studies. During that time Alex worked as a waiter, earning spending money while living at home. His work hours provided him with the flexibility to develop an online business that in the long run became a source of income. Alex enjoyed being independent and learning about the world through travel, reading and much You Tube video viewing. A year later, his goal was to be an entrepreneur and not re-enroll in university. Both parents were extremely upset with Alex and had tried to talk "some sense" into him, but to no avail. It was at this point that Penny- the mom requested a family session. During the first two sessions the therapist met once with the entire family in order to assess they viewed the problem; and once individually with Alex, in order to develop an alliance and get to know him better. Alex, was a slender young man with short blond hair, and green eyes. He appeared younger than his years and was soft spoken as he stated that he was eager to start the process. Alex perceived his mother as critical, with strong opinions about a college education and persistent about him returning to school. This made him angry and he said that he frequently avoided conversations with her because they always ended up on the topic of his future. Mom viewed her son as unreasonable, and disrespectful because he ignored her questions and refused to engage with her. She experienced him as spoiled, entitled and selfish; this made her feel frustrated. James agreed with his wife and said that the tension between Alex and his

**The Aldo Family: Presenting Concern and Relevant History**

mother stressed him, but he did not know what to do to resolve the issue.

Right from the start the EFFT therapist aims to understand the ways family members react to each other and tracks their interaction pattern. As family members discuss how they each perceive their concerns, reactive emotional responses are expressed or suppressed, thus allowing the therapist to witness the negative interaction pattern firsthand. The therapist tracks and reflects the behaviors that elicit the negative response and begins to identify the family pattern that is associated with the problem [3, 4]. It was obvious that this family was caught in a reactive pattern of defensiveness, which escalated with increasing anger and frustration. The family's escalation included mom trying to advise Alex and Alex avoiding the conversation.

*DOI: http://dx.doi.org/10.5772/intechopen.84320*

between the two of us.' Can you tell her this?"

*4.2.3 Creating enactments*

**5. Case illustration**

by the author is provided below:

#### *4.2.3 Creating enactments*

*Family Therapy - New Intervention Programs and Researches*

son, and that makes you feel so sad, so hurt inside."

Through the use of questions, evocative language, and metaphors the therapist opens up the client's experience and encourages them to take another step toward it Therapist: "What's happening right now as you hear him say that?" "What's it like for you when she follows you around the house, pushing for your attention?"

This intervention intensifies, clarifies, and deepens an emotion through persistent focus, reflection or enactments. Thus, allowing the client to identify and accept their emotional experience. The therapist's pacing, tone and timing are significant. The acronym RISSSC, implying emotional risk [3], represents how this intervention is done: with repetition, images, speaking simply, softly, slowly, and using client's words. The soft tone heightens vulnerability and sooths the dysregulated brain, so

Therapist: *"* This sounds really important, can we stay here for a bit, I think I hear you say that deep down you really go to a bad place, a place where you get the message that you are nothing but a failure in their eyes. A real disappointment for a

Therapist offers an interpretation of client's experience, or a hunch seen through the attachment lens. This facilitates a more intense experiencing from which new meanings may arise and an expanded awareness. It is important to convey tentativeness when offering a conjecture and to check if what is communicated matches the

Therapist*:* "As I listen to you, I hear you saying that you are angry about her lack of concern for you, but I see the tears in your eyes and I wonder if you are also say-

The following interventions are used in EFFT to address the restructuring task:

Reflections that track family members behaviors slow down and clarify the

Therapist: "So, when Alex gets frustrated and walks away ignoring what you say, you get angry too and follow him. You need him to listen to you. And, when your mom follows you around wanting your attention it makes you shut down even more."

Reframing interactions in the context of the negative cycle, and attachment needs. An attachment reframe functions to access a positive meaning or intention for a seemingly negative response. It shifts the view of the member to a

Therapist: "You don't experience that the louder she gets, the more desperately

she is trying to find you. It sounds as if she is upset with you, but she is doing

ing that you are hurt by her lack of concern. Does that seem to fit?"

*4.1.3 Evocative responding*

the client can process clearly.

*4.1.5 Empathic conjecture*

client's experience.

interactional process.

*4.2.2 Reframing*

positive portrayal.

**4.2 Restructuring interventions**

*4.2.1 Tracking, and reflecting interactions*

everything she can to get close to you."

*4.1.4 Heightening*

**28**

The therapist requests direct sharing of a clearly distilled message from one family member to another. Enactments, the most powerful intervention in EFFT, their function is to heighten emotional experience and reshape new interactions among family members which lead to positive cycles of accessibility and responsiveness.

Therapist: "Can you tell her, 'I go away because I don't want things to get worse between the two of us.' Can you tell her this?"

#### **5. Case illustration**

To help illustrate EFFT treatment in action, a case study of a family recently seen by the author is provided below:

#### **The Aldo Family: Presenting Concern and Relevant History**

The family is composed of James and Penny (names and identifying information have been altered), a professional couple in their early 50s, married for 28 years. They have two children; Ellie (23) and Alex (19). The couple has been on and off in couple therapy for a year. The presenting problem described by the parents focused on their son Alex, who had told them at the end of his third semester in college that he wanted to drop out because "this kind of education" was not for him, and he did not see how it would help him get a job. Both parents were very upset and after much discussion, hesitantly agreed to allow him to take a "gap year." It was their understanding that after the year break, Alex was to resume his studies. During that time Alex worked as a waiter, earning spending money while living at home. His work hours provided him with the flexibility to develop an online business that in the long run became a source of income. Alex enjoyed being independent and learning about the world through travel, reading and much You Tube video viewing. A year later, his goal was to be an entrepreneur and not re-enroll in university. Both parents were extremely upset with Alex and had tried to talk "some sense" into him, but to no avail. It was at this point that Penny- the mom requested a family session.

During the first two sessions the therapist met once with the entire family in order to assess they viewed the problem; and once individually with Alex, in order to develop an alliance and get to know him better. Alex, was a slender young man with short blond hair, and green eyes. He appeared younger than his years and was soft spoken as he stated that he was eager to start the process. Alex perceived his mother as critical, with strong opinions about a college education and persistent about him returning to school. This made him angry and he said that he frequently avoided conversations with her because they always ended up on the topic of his future. Mom viewed her son as unreasonable, and disrespectful because he ignored her questions and refused to engage with her. She experienced him as spoiled, entitled and selfish; this made her feel frustrated. James agreed with his wife and said that the tension between Alex and his mother stressed him, but he did not know what to do to resolve the issue.

Right from the start the EFFT therapist aims to understand the ways family members react to each other and tracks their interaction pattern. As family members discuss how they each perceive their concerns, reactive emotional responses are expressed or suppressed, thus allowing the therapist to witness the negative interaction pattern firsthand. The therapist tracks and reflects the behaviors that elicit the negative response and begins to identify the family pattern that is associated with the problem [3, 4]. It was obvious that this family was caught in a reactive pattern of defensiveness, which escalated with increasing anger and frustration. The family's escalation included mom trying to advise Alex and Alex avoiding the conversation.

The more mom insisted in engaging him the more Alex ignored her and she would get so upset that she would turn to her husband for help. James, not knowing what to do would try to calm her by promising he would talk to Alex. However, his approach was not successful either. The more they tried to talk to him or present him with consequences for his actions, the more Alex pulled away. The more he pulled away, the less valued they felt. It appeared to be a hopeless situation.

#### **5.1 EFFT therapeutic interventions**

#### *5.1.1 Stage one: Family De-escalation*

What follows is an actual dialog from the initial sessions with the family. This excerpt highlights the goal of stage one treatment to track the cycle between Alex and his mom and attempt to deescalate the tensions between family members.

ALEX: Well, yes… she is unbelievable. She asks me questions, a lot of questions about what I am going to do with my life and I do answer her but a few days later she is asking me the same questions!

THERAPIST: all these questions coming your way, regarding your future and you answer them, and then she asks again. Is that right?

ALEX: Yes, it's so frustrating because it's like, does she not remember? What's going on?

THERAPIST: I can understand your frustration- because, you wonder 'isn't what I say important enough to remember' Is that right?

ALEX: yes, that's exactly right.

THERAPIST: When your mom asks the same question, what happens inside you? What do you say to yourself?

ALEX: I hear myself saying, what is the point? I get frustrated.

THERAPIST: Are you feeling frustrated right now?

ALEX: Yes!

THERAPIST: Would you be willing to stay curious with me for a moment about this part that feels frustrated? Do you notice it somewhere in your body? (*staying with emotion in his body slows him down and intensifies the feeling).*

ALEX: I feel tightening in my chest and my shoulders.

THERAPIST: you hear your mom asking another question about your plans, you get frustrated, which you notice as a tightening in your chest and shoulders, is that right?

ALEX: yes.

THERAPIST: And then what does this frustrated part want to do or say to mom? ALEX: It wants to avoid her.

THERAPIST: How do you do that?

ALEX: By ignoring her and eventually leaving the room.

THERAPIST: What would happen if you did not ignore her and did not leave; if you stayed and talked with her?

ALEX: Nothing good would come out of that. I will only disappoint her again. There is no point.

THERAPIST: So, if talking makes it worse and you worry that you will disappoint her, then it makes sense that you do not want to engage. It sounds like when these fights happen there is nothing more to do but leave. Is that right?

ALEX: That seems to be the best option, right then and there.

THERAPIST: It makes sense to me that you leave the conversation to avoid making things worse between the two of you and, not disappoint your mom. Do you

**31**

*Emotionally Focused Family Therapy: Rebuilding Family Bonds*

do not want us to fight and I do not want to disappoint you.

THERAPIST: And when he walks away what happens to you?

this part that gets all fired up? Do you notice it somewhere in your body?

THERAPIST: And then what does this angry part do or say to Alex?

THERAPIST: What would happen if you did not do that?

think your mom knows this? Can you tell her that you leave in order to not escalate

ALEX: (turning to mom) I do not get into it with you and I walk away because I

THERAPIST: Yes (nodding). This is something new you are learning about Alex. The therapist also works with mom to identify her behaviors, thoughts and feel-

MOM: I get fired up and I follow him, and I ask again. I insist that he listens to

THERAPIST: Would you be willing to stay curious with me for a moment about

THERAPIST: you see Alex walk away, you get very angry, which you notice as a

ALEX: It gets very focused, very energized, and follows him relentlessly to get

ALEX: I would not know what he is up to and I would not be able to help him. I have good advice- I have been where Alex is now, and I can possibly spare him the heartache if he would talk with me. I worry that he will make a mistake, but he does

THERAPIST: You want Alex to value your advice. So, you get angry and you insist on engaging in a conversation in the hopes that you can help him see the value

THERAPIST: What does it feel like when you think that Alex does not value you?

THERAPIST: You want him to value you and your input and when he does not

THERAPIST: Do you think Alex knows that? What would it be like to share a little bit of that with him? That underneath your anger you feel sad because you

In the above excerpt the therapist looks at the pattern as it unfolds in the room between Alex and his mom. Family de-escalation occurs as Alex and his mom begin to understand their part in the negative interaction pattern and how their attachment-driven behaviors trigger predictable responses in each other. In this case every time mom needed to be assured that Alex was on the right path regarding his future, she asked questions which in turn triggered Alex and made him feel that an argument was imminent and he would disappoint his mother. He then pulled away to avoid the argument, leaving mom to feel sad and not valued and fearful that she was failing as a mother. This triggered mom and she then followed Alex around the house insisting that he engage with her. Alex would get more frustrated and eventually would leave the room thus confirming mom's fear of not

*DOI: http://dx.doi.org/10.5772/intechopen.84320*

ings as they relate to the negative cycle.

MOM: I feel tense all over.

tension all over your body, is that right?

things between the two of you?

MOM: I had no idea.

me and not ignore me.

MOM: Yes.

not value my input.

in what you say. Is that right? MOM: That's right.

MOM: (deep sigh) It feels sad.

that makes you feel sad. Is that right? MOM: (in soft voice) yes.

think that he does not value you? Can you tell him that?

*5.1.1.1 Treatment focus and progress in stage one*

his attention.

think your mom knows this? Can you tell her that you leave in order to not escalate things between the two of you?

ALEX: (turning to mom) I do not get into it with you and I walk away because I do not want us to fight and I do not want to disappoint you.

MOM: I had no idea.

*Family Therapy - New Intervention Programs and Researches*

**5.1 EFFT therapeutic interventions**

*5.1.1 Stage one: Family De-escalation*

is asking me the same questions!

ALEX: yes, that's exactly right.

you? What do you say to yourself?

ALEX: It wants to avoid her. THERAPIST: How do you do that?

you stayed and talked with her?

going on?

ALEX: Yes!

ALEX: yes.

There is no point.

right?

you answer them, and then she asks again. Is that right?

I say important enough to remember' Is that right?

The more mom insisted in engaging him the more Alex ignored her and she would get so upset that she would turn to her husband for help. James, not knowing what to do would try to calm her by promising he would talk to Alex. However, his approach was not successful either. The more they tried to talk to him or present him with consequences for his actions, the more Alex pulled away. The more he pulled away, the less valued they felt. It appeared to be a hopeless situation.

What follows is an actual dialog from the initial sessions with the family. This excerpt highlights the goal of stage one treatment to track the cycle between Alex and his mom and attempt to deescalate the tensions between family members.

ALEX: Well, yes… she is unbelievable. She asks me questions, a lot of questions about what I am going to do with my life and I do answer her but a few days later she

THERAPIST: all these questions coming your way, regarding your future and

ALEX: Yes, it's so frustrating because it's like, does she not remember? What's

THERAPIST: When your mom asks the same question, what happens inside

THERAPIST: Would you be willing to stay curious with me for a moment about this part that feels frustrated? Do you notice it somewhere in your body? (*staying* 

THERAPIST: you hear your mom asking another question about your plans, you get frustrated, which you notice as a tightening in your chest and shoulders, is that

THERAPIST: And then what does this frustrated part want to do or say to mom?

THERAPIST: What would happen if you did not ignore her and did not leave; if

ALEX: Nothing good would come out of that. I will only disappoint her again.

THERAPIST: So, if talking makes it worse and you worry that you will disappoint her, then it makes sense that you do not want to engage. It sounds like when

THERAPIST: It makes sense to me that you leave the conversation to avoid making things worse between the two of you and, not disappoint your mom. Do you

ALEX: I hear myself saying, what is the point? I get frustrated.

*with emotion in his body slows him down and intensifies the feeling).* ALEX: I feel tightening in my chest and my shoulders.

ALEX: By ignoring her and eventually leaving the room.

these fights happen there is nothing more to do but leave. Is that right? ALEX: That seems to be the best option, right then and there.

THERAPIST: Are you feeling frustrated right now?

THERAPIST: I can understand your frustration- because, you wonder 'isn't what

**30**

THERAPIST: Yes (nodding). This is something new you are learning about Alex.

The therapist also works with mom to identify her behaviors, thoughts and feelings as they relate to the negative cycle.

THERAPIST: And when he walks away what happens to you?

MOM: I get fired up and I follow him, and I ask again. I insist that he listens to me and not ignore me.

THERAPIST: Would you be willing to stay curious with me for a moment about this part that gets all fired up? Do you notice it somewhere in your body?

MOM: I feel tense all over.

THERAPIST: you see Alex walk away, you get very angry, which you notice as a tension all over your body, is that right?

MOM: Yes.

THERAPIST: And then what does this angry part do or say to Alex?

ALEX: It gets very focused, very energized, and follows him relentlessly to get his attention.

THERAPIST: What would happen if you did not do that?

ALEX: I would not know what he is up to and I would not be able to help him. I have good advice- I have been where Alex is now, and I can possibly spare him the heartache if he would talk with me. I worry that he will make a mistake, but he does not value my input.

THERAPIST: You want Alex to value your advice. So, you get angry and you insist on engaging in a conversation in the hopes that you can help him see the value in what you say. Is that right?

MOM: That's right.

THERAPIST: What does it feel like when you think that Alex does not value you? MOM: (deep sigh) It feels sad.

THERAPIST: You want him to value you and your input and when he does not that makes you feel sad. Is that right?

MOM: (in soft voice) yes.

THERAPIST: Do you think Alex knows that? What would it be like to share a little bit of that with him? That underneath your anger you feel sad because you think that he does not value you? Can you tell him that?

#### *5.1.1.1 Treatment focus and progress in stage one*

In the above excerpt the therapist looks at the pattern as it unfolds in the room between Alex and his mom. Family de-escalation occurs as Alex and his mom begin to understand their part in the negative interaction pattern and how their attachment-driven behaviors trigger predictable responses in each other. In this case every time mom needed to be assured that Alex was on the right path regarding his future, she asked questions which in turn triggered Alex and made him feel that an argument was imminent and he would disappoint his mother. He then pulled away to avoid the argument, leaving mom to feel sad and not valued and fearful that she was failing as a mother. This triggered mom and she then followed Alex around the house insisting that he engage with her. Alex would get more frustrated and eventually would leave the room thus confirming mom's fear of not being valued. The therapist helps both uncover these deeper emotions and then invites them to do an enactment. In other words, to turn toward each other and engage in a different conversation. Until now, neither was aware how they protected themselves in their relationship nor had they been able to talk about their underlying feelings. The enactment is successful, and both Alex and mom have a new understanding about each other's behavior. He expresses that he values her and wants to be able to talk with her without arguing because it does not feel good to either of them. They both share in the new experience of staying engaged. This awareness shifts the focus from blaming each other to owing their contribution in the negative cycle. In turn, this begins to alter their experience; they feel calmer and more open. A level of safety is created that will allow us to go deeper into vulnerabilities in the next stage.

#### *5.1.2 Stage two: Restructuring family interactions*

What follows below is an example of actual dialog used to illustrate the process of restructuring family dynamics:

THERAPIST: A few sessions ago you talked about feeling sad because you see yourself as a disappointment for your parents. Do you remember?

ALEX: Mhmm.

THERAPIST: I guess, I am curious to know, more about this place that you go to… when you feel that… you are a disappointment. Is it okay for us to go to that place?

ALEX: Sure. (pause) It's pretty bad. I try not to think about it. Instead, I just try to focus and work harder.

THERAPIST: It's so bad that you try to not think about it? Right now as we are thinking about it, talking about, notice what happens in your body.

ALEX: I feel flushed and I feel tightness in my throat. It's a bad feeling. That's why I do not like to think about it.

THERAPIST: Sure, it makes sense. And… who sees you in that place? Who knows about that?

ALEX: Nobody knows. Nobody sees how much I try to make them proud of me. Instead I am told that everything I do is wrong. My whole approach is wrong, I am all wrong! (eyes closed).

THERAPIST: That's really painful—it's hard for you.

(Long Pause)

ALEX: Sometimes it feels that I might be running out of time… you know… my dad had problems with his heart last year. (At this point Alex, with his eyes closed and tears running down his cheeks, can hardly speak. After a long pause he continues). I am afraid that I might not have the chance to prove myself and it will be too late. And that maybe I should give up on my ideas and listen to theirs because it will be faster, but then I get conflicted and I think that, it's not right to do something that I do not believe in. And I really believe in this. I do not want to disappoint them but I do not want to disappoint myself either.

THERAPIST: Wow! It feels like you are running against time and you have to choose - your parents or yourself. Neither is a good option; and so you go here and you struggle, and you are confused and scared and alone trying to figure things out.

Alex is sobbing, and his dad reaches over and hugs him. His mom moves over and she too, sits beside him and hugs him.

THERAPIST: Alex, your parents are right beside you. They want to understand. Can you let them in to that place where you are alone and sad?

ALEX: I am scared when I think that something suddenly might happen to dad or to you (mom) like last year- and then you would not have the chance to see what I

**33**

*Emotionally Focused Family Therapy: Rebuilding Family Bonds*

accomplished and be proud of me. Then you will never know that I am capable and

THERAPIST: That is scary, to think that something might happen to either of your parents and trying to prove yourself, trying to get it right and not disappoint

DAD: I am so sorry that you are so hurt. I am, *we* are not disappointed in you and *we* do not want to "fix you" or "change you". We love you no matter what you do and now that I know I will do anything to be there for you. I am sorry that our pushingour way of trying to help you caused you so much pain. We love you and want to

ALEX: I could leave the house, but I really want to work on our relationship, because it is important that I, have both of your "blessings" as I move on. It is important, that I leave "the nest" as you say, knowing that you are proud of me and you love me, even if I failed. It's like, the baby bird trying to fly out of the nest. The parents have to trust that he can do it- although they may not know for sure. If the baby bird falls, he needs his parents to lovingly encourage him to try again. Sometimes, he flops around for a little bit before the parents rush in to help, and that is ok. The little bird is learning even if he falls, even if he breaks a wing. Keeping the bird in the nest or constantly giving him directions how to fly is constraining—he will not find *his* way. I guess what I am asking is… do you think you can be there as I try to figure things out? I want to find *my* way and can you trust

that I will be okay–without flying in to help me or try to change my path?

incredible to hear what has been going on for you."

there for you. I don't want you to feel this way."

*5.1.2.1 Treatment focus and progress in stage two*

a small pause, with tears in her eyes says:

DAD: "I had no idea that you felt this way; that you have been trying to fly out of the nest. I didn't see all this as your attempt in figuring things out. What I thought I saw, was a little bird taking advantage of the safety provided by our nest and unless we pushed, you were not going to fly. I see now how that hurt you and how it made you feel that we didn't trust you. I love you and want to support you and it's pretty

At this point Alex is weeping in his father's arms. Mom joins in the hug and after

MOM: "I am so sorry I hurt you. I get scared and I rush in to help you, to save you, to show you and that makes you feel that I don't believe in you. I want to be

In the above excerpt, Alex begins to talk about how scary it is to feel that he disappoints his parents and how he wants to make them proud before he loses either of them. His parents remain open hearted and open minded as he engages with them from a vulnerable place. They see his pain, hurt and fear. Dad not only sees from afar this terrible place that his son struggles in but can stand side by side with him there. His presence is felt, and his apology makes a huge difference to Alex. For the first time, Alex feels seen and feels understood at a much deeper level and therefore, this allows Alex to clearly articulate his attachment needs. Mom and dad worked together to respond to Alex. Often parents cannot empathize because they get caught up in their own secondary responses of fear. Staying present with Alex in his vulnerability allowed both parents to experience how Alex's problematic behavior was related to the family's negative cycle of interaction. In a later session, both parents were able to articulate their fear of failure and Alex was able to hear this and understand much of their stress as parents. He then reassured them, "you have been great parents, given me so much. I hope to be able to offer my kids what you have offered me. I love you both and I don't want you to feel that you have failed as parents." Additionally, he expressed regret for his past behavior toward his mother.

*DOI: http://dx.doi.org/10.5772/intechopen.84320*

support you, in a way that is best for you.

that it's ok to do it my way.

while you still have time.

*Family Therapy - New Intervention Programs and Researches*

vulnerabilities in the next stage.

of restructuring family dynamics:

why I do not like to think about it.

ALEX: Mhmm.

to focus and work harder.

knows about that?

all wrong! (eyes closed).

(Long Pause)

*5.1.2 Stage two: Restructuring family interactions*

being valued. The therapist helps both uncover these deeper emotions and then invites them to do an enactment. In other words, to turn toward each other and engage in a different conversation. Until now, neither was aware how they protected themselves in their relationship nor had they been able to talk about their underlying feelings. The enactment is successful, and both Alex and mom have a new understanding about each other's behavior. He expresses that he values her and wants to be able to talk with her without arguing because it does not feel good to either of them. They both share in the new experience of staying engaged. This awareness shifts the focus from blaming each other to owing their contribution in the negative cycle. In turn, this begins to alter their experience; they feel calmer and more open. A level of safety is created that will allow us to go deeper into

What follows below is an example of actual dialog used to illustrate the process

THERAPIST: A few sessions ago you talked about feeling sad because you see

THERAPIST: I guess, I am curious to know, more about this place that you go to… when you feel that… you are a disappointment. Is it okay for us to go to that place? ALEX: Sure. (pause) It's pretty bad. I try not to think about it. Instead, I just try

THERAPIST: It's so bad that you try to not think about it? Right now as we are

ALEX: I feel flushed and I feel tightness in my throat. It's a bad feeling. That's

ALEX: Nobody knows. Nobody sees how much I try to make them proud of me. Instead I am told that everything I do is wrong. My whole approach is wrong, I am

ALEX: Sometimes it feels that I might be running out of time… you know… my dad had problems with his heart last year. (At this point Alex, with his eyes closed and tears running down his cheeks, can hardly speak. After a long pause he continues). I am afraid that I might not have the chance to prove myself and it will be too late. And that maybe I should give up on my ideas and listen to theirs because it will be faster, but then I get conflicted and I think that, it's not right to do something that I do not believe in. And I really believe in this. I do not want to disappoint them

THERAPIST: Wow! It feels like you are running against time and you have to choose - your parents or yourself. Neither is a good option; and so you go here and you struggle, and you are confused and scared and alone trying to figure things out. Alex is sobbing, and his dad reaches over and hugs him. His mom moves over

THERAPIST: Alex, your parents are right beside you. They want to understand.

ALEX: I am scared when I think that something suddenly might happen to dad or to you (mom) like last year- and then you would not have the chance to see what I

THERAPIST: Sure, it makes sense. And… who sees you in that place? Who

yourself as a disappointment for your parents. Do you remember?

thinking about it, talking about, notice what happens in your body.

THERAPIST: That's really painful—it's hard for you.

Can you let them in to that place where you are alone and sad?

but I do not want to disappoint myself either.

and she too, sits beside him and hugs him.

**32**

accomplished and be proud of me. Then you will never know that I am capable and that it's ok to do it my way.

THERAPIST: That is scary, to think that something might happen to either of your parents and trying to prove yourself, trying to get it right and not disappoint while you still have time.

DAD: I am so sorry that you are so hurt. I am, *we* are not disappointed in you and *we* do not want to "fix you" or "change you". We love you no matter what you do and now that I know I will do anything to be there for you. I am sorry that our pushingour way of trying to help you caused you so much pain. We love you and want to support you, in a way that is best for you.

ALEX: I could leave the house, but I really want to work on our relationship, because it is important that I, have both of your "blessings" as I move on. It is important, that I leave "the nest" as you say, knowing that you are proud of me and you love me, even if I failed. It's like, the baby bird trying to fly out of the nest. The parents have to trust that he can do it- although they may not know for sure. If the baby bird falls, he needs his parents to lovingly encourage him to try again. Sometimes, he flops around for a little bit before the parents rush in to help, and that is ok. The little bird is learning even if he falls, even if he breaks a wing. Keeping the bird in the nest or constantly giving him directions how to fly is constraining—he will not find *his* way. I guess what I am asking is… do you think you can be there as I try to figure things out? I want to find *my* way and can you trust that I will be okay–without flying in to help me or try to change my path?

DAD: "I had no idea that you felt this way; that you have been trying to fly out of the nest. I didn't see all this as your attempt in figuring things out. What I thought I saw, was a little bird taking advantage of the safety provided by our nest and unless we pushed, you were not going to fly. I see now how that hurt you and how it made you feel that we didn't trust you. I love you and want to support you and it's pretty incredible to hear what has been going on for you."

At this point Alex is weeping in his father's arms. Mom joins in the hug and after a small pause, with tears in her eyes says:

MOM: "I am so sorry I hurt you. I get scared and I rush in to help you, to save you, to show you and that makes you feel that I don't believe in you. I want to be there for you. I don't want you to feel this way."

#### *5.1.2.1 Treatment focus and progress in stage two*

In the above excerpt, Alex begins to talk about how scary it is to feel that he disappoints his parents and how he wants to make them proud before he loses either of them. His parents remain open hearted and open minded as he engages with them from a vulnerable place. They see his pain, hurt and fear. Dad not only sees from afar this terrible place that his son struggles in but can stand side by side with him there. His presence is felt, and his apology makes a huge difference to Alex. For the first time, Alex feels seen and feels understood at a much deeper level and therefore, this allows Alex to clearly articulate his attachment needs. Mom and dad worked together to respond to Alex. Often parents cannot empathize because they get caught up in their own secondary responses of fear. Staying present with Alex in his vulnerability allowed both parents to experience how Alex's problematic behavior was related to the family's negative cycle of interaction. In a later session, both parents were able to articulate their fear of failure and Alex was able to hear this and understand much of their stress as parents. He then reassured them, "you have been great parents, given me so much. I hope to be able to offer my kids what you have offered me. I love you both and I don't want you to feel that you have failed as parents." Additionally, he expressed regret for his past behavior toward his mother.

Alex began to ask for contact, and this continued in following sessions which helped to bring them closer together.

#### *5.1.3 Stage three: Consolidation*

What follows below is an example of actual dialog used to illustrate the process of consolidation:

MOM: Things are good. Alex initiated a conversation earlier this week where he confided in me and asked for my advice. He was telling me about an incident that happened at work and how he handled it. And then asked for my opinion–how I would have handled it.

ALEX: (smiling) "That was nice, and different than times in the past. She did not do anything, other than just listen.

(Turning toward his mom) You did not try to fix or problem solve with me the way you used to with all the questions. You listened to me for a long time and then I remember that I asked you for advice. You said that you agreed with how I handled the matter and you would have done the same. It really felt good to talk to you like an adult without running away or avoiding you. I want to say, thank you for that because I feel less tense and more relaxed.

THERAPIST: That's really great Alex that you felt good to approach your mom and discuss something that was important to you and ask for her input. And it sounds that you both had this conversation in a different way than before. In a way that even feels different in your body.

ALEX: Yes. Growing up and doing things differently than the way your parents expect is hard and can be kind of scary. Knowing that they are open and that my mom is there without judging me feels great.

MOM: I am so glad that we turned a corner. I am always here for you, no matter what and I want to be the mom you want me to be.

#### *5.1.3.1 Treatment focus and progress in stage three*

In the above excerpt mom discovers during treatment that she could help her son by her attentive presence. She understands that she did not have to solve Alex's problems or go "undercover" to find out what he was doing and, as a result, this helped her stay more connected with him. The relationship became safer, closer, and more equal. Both were able to confide in and support each other which is the desired outcome for stage three treatment.

#### **6. Conclusions**

Treating families in distress is extremely challenging for family therapists. Professionals working with families, especially neophytes, commonly feel uncertain and discouraged as they attempt to navigate the vast landscape of family dynamics encompassing multiple, complex interpersonal processes between members. As a result, family therapists find themselves negotiating or offering solutions to presenting problems, rather than focus on the underlying issues that are at the root cause of the dysfunction. Unfortunately, they soon realize the techniques used are not effective, and before long the family members cycle back where they started from. This makes the therapists feel inefficient and ineffective and therefore may shy away from doing family work.

Having access to a practical, organized and effective model for working with families is pivotal if practitioners are to make meaningful differences in the lives of

**35**

USA

**Author details**

Katherine Stavrianopoulos

provided the original work is properly cited.

\*Address all correspondence to: stavros@jjay.cuny.edu

*Emotionally Focused Family Therapy: Rebuilding Family Bonds*

people they serve. EFFT arose from the realization that the change principles used in EFT could be applied to family relationships thus changing the cycles of interaction [3]. EFFT is a powerful and efficient way to assess and create positive change within the family system. At its core, EFFT views family distress as a result of attachment insecurity where family members fail to get their attachment needs met. Such families do not possess the skills necessary in expressing their attachment needs and protect themselves by becoming defensive, beginning a negative cycle of interaction which prevents healthy family functioning and stability. Accessing underlying attachment-related emotions and the needs associated with these emotions opens the family to address needs in new ways [3]. Corrective emotional experiences create safety that change family relationships and most likely impact future generations. Tapping into parents' unconditional love is powerful; it offers families great hope

and holds tremendous promise in revitalizing the field of family therapy.

*DOI: http://dx.doi.org/10.5772/intechopen.84320*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

John Jay College of Criminal Justice, The City University of New York, New York,

#### *Emotionally Focused Family Therapy: Rebuilding Family Bonds DOI: http://dx.doi.org/10.5772/intechopen.84320*

*Family Therapy - New Intervention Programs and Researches*

to bring them closer together.

*5.1.3 Stage three: Consolidation*

of consolidation:

would have handled it.

not do anything, other than just listen.

because I feel less tense and more relaxed.

that even feels different in your body.

mom is there without judging me feels great.

what and I want to be the mom you want me to be.

*5.1.3.1 Treatment focus and progress in stage three*

desired outcome for stage three treatment.

shy away from doing family work.

**6. Conclusions**

Alex began to ask for contact, and this continued in following sessions which helped

What follows below is an example of actual dialog used to illustrate the process

MOM: Things are good. Alex initiated a conversation earlier this week where he confided in me and asked for my advice. He was telling me about an incident that happened at work and how he handled it. And then asked for my opinion–how I

ALEX: (smiling) "That was nice, and different than times in the past. She did

(Turning toward his mom) You did not try to fix or problem solve with me the way you used to with all the questions. You listened to me for a long time and then I remember that I asked you for advice. You said that you agreed with how I handled the matter and you would have done the same. It really felt good to talk to you like an adult without running away or avoiding you. I want to say, thank you for that

THERAPIST: That's really great Alex that you felt good to approach your mom and discuss something that was important to you and ask for her input. And it sounds that you both had this conversation in a different way than before. In a way

ALEX: Yes. Growing up and doing things differently than the way your parents expect is hard and can be kind of scary. Knowing that they are open and that my

MOM: I am so glad that we turned a corner. I am always here for you, no matter

In the above excerpt mom discovers during treatment that she could help her son by her attentive presence. She understands that she did not have to solve Alex's problems or go "undercover" to find out what he was doing and, as a result, this helped her stay more connected with him. The relationship became safer, closer, and more equal. Both were able to confide in and support each other which is the

Treating families in distress is extremely challenging for family therapists. Professionals working with families, especially neophytes, commonly feel uncertain and discouraged as they attempt to navigate the vast landscape of family dynamics encompassing multiple, complex interpersonal processes between members. As a result, family therapists find themselves negotiating or offering solutions to presenting problems, rather than focus on the underlying issues that are at the root cause of the dysfunction. Unfortunately, they soon realize the techniques used are not effective, and before long the family members cycle back where they started from. This makes the therapists feel inefficient and ineffective and therefore may

Having access to a practical, organized and effective model for working with families is pivotal if practitioners are to make meaningful differences in the lives of

**34**

people they serve. EFFT arose from the realization that the change principles used in EFT could be applied to family relationships thus changing the cycles of interaction [3]. EFFT is a powerful and efficient way to assess and create positive change within the family system. At its core, EFFT views family distress as a result of attachment insecurity where family members fail to get their attachment needs met. Such families do not possess the skills necessary in expressing their attachment needs and protect themselves by becoming defensive, beginning a negative cycle of interaction which prevents healthy family functioning and stability. Accessing underlying attachment-related emotions and the needs associated with these emotions opens the family to address needs in new ways [3]. Corrective emotional experiences create safety that change family relationships and most likely impact future generations. Tapping into parents' unconditional love is powerful; it offers families great hope and holds tremendous promise in revitalizing the field of family therapy.

### **Author details**

Katherine Stavrianopoulos

John Jay College of Criminal Justice, The City University of New York, New York, USA

\*Address all correspondence to: stavros@jjay.cuny.edu

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Bloch L, Guillory PT. The attachment frame is the thing: Emotion-focused family therapy in adolescence. Journal of Couple & Relationship Therapy. 2011;**10**(3):229-245

[2] Stavrianopoulos K, Faller G, Furrow JL. Emotionally focused family therapy: Facilitating change within a family system. Journal of Couple & Relationship Therapy. 2014;**13**(1):25-43

[3] Johnson SM. The Practice of Emotionally Focused Couple Therapy: Creating Connection. 2nd ed. New York (NY): Brunner-Routledge; 2004

[4] Johnson SM. The Practice of Emotionally Focused Marital Therapy: Creating Connection. New York (NY): Brunner/Mazel; 1996

[5] Rogers CR. Client-Centered Therapy. Boston: Houghton-Mifflin; 1951

[6] Minuchin S, Fishman HC. Family Therapy Techniques. Cambridge (MA): Harvard University Press; 1981

[7] Bowlby JA. Secure Base. New York (NY): Basic Books; 1988

[8] Karen R. Becoming Attached: First Relationships and how they Shape our Capacity to Love. New York (NY): Oxford University Press; 1994

[9] Bowlby J. Attachment and Loss: Separation. Vol. 2. New York (NY): Basic Books; 1973

[10] Johnson SM. Emotionally Focused Couple Therapy with Trauma Survivors: Strengthening Attachment Bonds. New York (NY): Guildford Press; 2002

[11] Kobak R. The emotional dynamics of disruption in attachment relationships: Implications for theory, research, and clinical intervention. In: Cassidy J, Shaver P, editors. Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guildford Press; 1999. pp. 21-43

[12] Shaver PR, Mikulincer M. Attachment-related psychodynamics. Attachment & Human Development. 2002;**4**:133-161

[13] Mikulincer M, Shaver PR. Attachment in Adulthood: Structure, Dynamics, and Change. 2nd ed. New York: Guildford Press; 2016

[14] Johnson SM. Listening to the music: Emotion as a natural part of systems theory. Journal of Systemic Therapies. 1998;**17**:1-17

[15] Kobak R, Mandelbaum T. Caring for the caregiver: An attachment approach to assessment and treatment of child problems. In: Johnson S, Whiffen V, editors. Attachment Process in Couple and Family Therapy. New York: Guildford Press; 2003. pp. 144-164

[16] Miccuci JA. The Adolescent in Family Therapy: Breaking the Cycle of Conflict and Control. New York: Guildford Press; 1998

[17] Palmer G, Efron D. Emotionally focused family therapy: Developing the model. Journal of Systemic Therapies. 2007;**26**:17-24

[18] Johnson SM, Bradley B, Furrow J, et al. Becoming an Emotionally Focused Couple Therapist; the Workbook. New York: Brunner-Routledge; 2005

**37**

**Chapter 3**

**Abstract**

to face their difficulties.

**1. Introduction**

Family Therapy: New Intervention

Programs and Researches: Systemic

Talking about family practice is talking about family systemic approach. There are many cues that are so important to understand how the family functions. This is the scope of systemic family approach, where the health is influenced by all the systems a person belongs. In this chapter, we will discuss how a family interacts and the roles of every person in the family—as individuals and as part of the context. And most of it is how this interaction influences the health of every member of the family. Based on the systemic theory, we will run over some tools that will allow to assess the family and discuss how to ease the communication and to help the family

**Keywords:** systemic thinking, complexity, systemic family therapy, intervention tools

There is a huge evolution on the health care, medicine, nursery, psychology, pharmacy, and many others fields of care, but most of it has been based on tradi-

Many authors had emphasized the need to understand how things are happening and why there are differences between individuals. That is where we find out a new paradigm which is emerging from everywhere but specially in the health field. As the evolution of scientific research in the field of health is more focused on the biomedical model, the emergence of a new paradigmatic movement proposes the reading and understanding of the health/disease interface through the multidetermination of the elements that compose it; according to Khun [1], p. 126, "Scientific revolutions begin with a growing feeling, then also restricted to a small division of the scientific community, that the existing paradigm no longer functions properly in the exploration of an aspect of nature whose exploitation previously driven by the dominant paradigm." The disease is no longer understood only from the biological point of view, and today it has a very complex conceptual expansion, involving physical, psychologi-

Systemic thinking does not deny the importance of traditional research, but it is realized that it is not enough to answer the differences between individuals and does not answer many questions about why people suffer of something. So it is necessary to open the mind for these paradigms, where things are complex and complexity will allow the recognition of how to understand and help people and their context

tional science that analyzes details, but it misses the context.

cal, social, cultural, spiritual, and ecological dimensions.

to face the challenges life is presenting.

Family Approach in Health Care

*Hamilton Lima Wagner and Tania Dalallana*

#### **Chapter 3**

## Family Therapy: New Intervention Programs and Researches: Systemic Family Approach in Health Care

*Hamilton Lima Wagner and Tania Dalallana*

#### **Abstract**

Talking about family practice is talking about family systemic approach. There are many cues that are so important to understand how the family functions. This is the scope of systemic family approach, where the health is influenced by all the systems a person belongs. In this chapter, we will discuss how a family interacts and the roles of every person in the family—as individuals and as part of the context. And most of it is how this interaction influences the health of every member of the family. Based on the systemic theory, we will run over some tools that will allow to assess the family and discuss how to ease the communication and to help the family to face their difficulties.

**Keywords:** systemic thinking, complexity, systemic family therapy, intervention tools

#### **1. Introduction**

There is a huge evolution on the health care, medicine, nursery, psychology, pharmacy, and many others fields of care, but most of it has been based on traditional science that analyzes details, but it misses the context.

Many authors had emphasized the need to understand how things are happening and why there are differences between individuals. That is where we find out a new paradigm which is emerging from everywhere but specially in the health field. As the evolution of scientific research in the field of health is more focused on the biomedical model, the emergence of a new paradigmatic movement proposes the reading and understanding of the health/disease interface through the multidetermination of the elements that compose it; according to Khun [1], p. 126, "Scientific revolutions begin with a growing feeling, then also restricted to a small division of the scientific community, that the existing paradigm no longer functions properly in the exploration of an aspect of nature whose exploitation previously driven by the dominant paradigm."

The disease is no longer understood only from the biological point of view, and today it has a very complex conceptual expansion, involving physical, psychological, social, cultural, spiritual, and ecological dimensions.

Systemic thinking does not deny the importance of traditional research, but it is realized that it is not enough to answer the differences between individuals and does not answer many questions about why people suffer of something. So it is necessary to open the mind for these paradigms, where things are complex and complexity will allow the recognition of how to understand and help people and their context to face the challenges life is presenting.

**36**

*Family Therapy - New Intervention Programs and Researches*

of Attachment: Theory, Research, and Clinical Applications. New York: Guildford Press; 1999. pp. 21-43

[12] Shaver PR, Mikulincer M.

[13] Mikulincer M, Shaver PR. Attachment in Adulthood: Structure, Dynamics, and Change. 2nd ed. New York: Guildford Press; 2016

2002;**4**:133-161

1998;**17**:1-17

Attachment-related psychodynamics. Attachment & Human Development.

[14] Johnson SM. Listening to the music: Emotion as a natural part of systems theory. Journal of Systemic Therapies.

[15] Kobak R, Mandelbaum T. Caring for the caregiver: An attachment approach to assessment and treatment of child problems. In: Johnson S, Whiffen V, editors. Attachment Process in Couple and Family Therapy. New York: Guildford Press; 2003. pp. 144-164

[16] Miccuci JA. The Adolescent in Family Therapy: Breaking the Cycle of Conflict and Control. New York:

[17] Palmer G, Efron D. Emotionally focused family therapy: Developing the model. Journal of Systemic Therapies.

[18] Johnson SM, Bradley B, Furrow J, et al. Becoming an Emotionally Focused Couple Therapist; the Workbook. New York: Brunner-Routledge; 2005

Guildford Press; 1998

2007;**26**:17-24

[1] Bloch L, Guillory PT. The attachment frame is the thing: Emotion-focused family therapy in adolescence. Journal of Couple & Relationship Therapy.

2011;**10**(3):229-245

**References**

[2] Stavrianopoulos K, Faller G,

[3] Johnson SM. The Practice of Emotionally Focused Couple Therapy: Creating Connection. 2nd ed. New York

(NY): Brunner-Routledge; 2004

[4] Johnson SM. The Practice of Emotionally Focused Marital Therapy: Creating Connection. New York (NY):

Boston: Houghton-Mifflin; 1951

Harvard University Press; 1981

(NY): Basic Books; 1988

Books; 1973

[5] Rogers CR. Client-Centered Therapy.

[6] Minuchin S, Fishman HC. Family Therapy Techniques. Cambridge (MA):

[7] Bowlby JA. Secure Base. New York

[8] Karen R. Becoming Attached: First Relationships and how they Shape our Capacity to Love. New York (NY): Oxford University Press; 1994

[9] Bowlby J. Attachment and Loss: Separation. Vol. 2. New York (NY): Basic

[10] Johnson SM. Emotionally Focused Couple Therapy with Trauma Survivors: Strengthening Attachment Bonds. New York (NY): Guildford Press; 2002

dynamics of disruption in attachment relationships: Implications for theory, research, and clinical intervention. In: Cassidy J, Shaver P, editors. Handbook

[11] Kobak R. The emotional

Brunner/Mazel; 1996

Furrow JL. Emotionally focused family therapy: Facilitating change within a family system. Journal of Couple & Relationship Therapy. 2014;**13**(1):25-43

Since 1975, Bertalanffy [3] had introduced the systemic thinking in health assistance, but it was Morin in the beginning of the 1970s who had started to talk about complexity and its implication on modern science. From these time and forward, many authors had produced research over these fields, and one of them—Ian McWhiney, a family doctor—had pointed that there is a need of a new approach to offer a health assistance that allows a view of the entire system and to recognize that the ill and illness are part of lifestyle, relations, and social conditions.

Simultaneously, the biopsychosocial model had been proposed by Engel in 1977, and the family theory had started to produce its first researches. The new paradigm recognizes that there are no observers that are out of the system, and it means that their own knowledge and life story will have some influence in the results. That is a major change in the research field and shows one of the big challenges to everyone who works on this field.

#### **2. Systemic family thinking**

As long as it is accepted that the family is a system, part of the society where it belongs, many issues appear to be of concern—first is that any system desires to keep its functionality. As a living system, they want to discover their own rules to work, the society rules that allow interaction with other families and organizations of this community. But also they have to admit that each member has their own necessities and will develop according to their possibilities.

That system needs to grow and differentiate to survive, and any movement in every part of the system can challenge the role of the system. This concept shows the complexity to work on this field, but it opens the possibility to understand why people suffer and in the meantime can have some illness or even if nothing can be done can develop an ill.

Life is very complex; we deal with changes in our body, during the time and with the relations with our family—creating a huge challenge to adapt each one with these. But few persons are aware with these challenges. Mostly, they say that is a phase or a crisis, and they do not realize that each moment can stress the system and can develop some noise on the relation.

Every system has roles that must be assumed by their members, and as long it is well divided, it will work more easily; but most of the time, this task division is unfair for some of the members, and it can create stress factors. Every member of the system has some expectations about the others members, and generally it is not clear for everyone what is expected. Members of any human group will interact based on their feelings, but also over the expectations of their counterparts, but they used to understand the others by reflecting over themselves.

This is the field where a systemic professional must work. And there is much more: every person has been built based on the roles that they found early in their lives, as long as they saw the childhood of their mothers and fathers and how the adults related to each other—everyone brings these in their personality, and the ability to face this challenge is the key to the family success (**Figure 1**).

The fortress that every person possesses is based on the skills developed during the childhood: ability to feed, to bond to each other, to organize life, to be protected and to protect others, to find their own limits and to define others' limits, and how to drive their own feelings in any direction. Their learnings are essential for a person to relate with the world that surrounds them. But friendship, affection, and sexuality are also developed in this environment [3].

**39**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

by individuals and groups. And the way to describe these situations needs to be understood in order to allow a therapeutic approach and offer some paths to people

Working with families can be divided into different steps in a different way for better explanation and understanding [6]. The use of these steps depends on the given situation and the needs of each family served. The following phases can be identified schematically: association, evaluation, health education, facilitation, and reference.

Associating with the patient and their family is a fundamental requirement for the construction of the therapeutic process that should be actively pursued. The interaction of the professional with the patient is rich when the former can respect the reality and beliefs of the latter, which is often very difficult. The reality of

people's lives is very diverse and demands from the professional a careful observation not to slip into attitudes centered on their own way of seeing life and to believe in solutions based on their core of knowledge. Almost all people receive good advice when they reflect their way of seeing and feeling an item; the attitude of the professional to perceive the situations by their angle of vision can put him in confrontation with the patient and his family, leading to a break in the relationship between them. Often the professional's lack of practice in working with families leads to the difficulty of understanding why it is necessary to meet with family groups or even to visualize the feelings of each patient. Freire [7], in one of his several texts on pedagogy, approaches in a very clear way the need for the perception of personal experiences in the construction of effective communication. For this communication to take place, it must be based on the lived reality and be of adequate complex-

The professional who intends to perform his task of promoting the health of the community where he serves should be able to seek association with patients and their families. In order for this attempt to be achieved, there are some important

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

to have a better life.

*Schematic functioning of the family system.*

**Figure 1.**

**3.1 Family connection**

ity to the person to be reached.

steps to remember:

**3. The steps to working with families**

It is clear that knowing about the family development allows the professional to have a better understanding about the difficulties that have been faced *Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

**Figure 1.** *Schematic functioning of the family system.*

*Family Therapy - New Intervention Programs and Researches*

who works on this field.

done can develop an ill.

can develop some noise on the relation.

ity are also developed in this environment [3].

**2. Systemic family thinking**

Since 1975, Bertalanffy [3] had introduced the systemic thinking in health assistance, but it was Morin in the beginning of the 1970s who had started to talk about complexity and its implication on modern science. From these time and forward, many authors had produced research over these fields, and one of them—Ian McWhiney, a family doctor—had pointed that there is a need of a new approach to offer a health assistance that allows a view of the entire system and to recognize that

Simultaneously, the biopsychosocial model had been proposed by Engel in 1977, and the family theory had started to produce its first researches. The new paradigm recognizes that there are no observers that are out of the system, and it means that their own knowledge and life story will have some influence in the results. That is a major change in the research field and shows one of the big challenges to everyone

As long as it is accepted that the family is a system, part of the society where it belongs, many issues appear to be of concern—first is that any system desires to keep its functionality. As a living system, they want to discover their own rules to work, the society rules that allow interaction with other families and organizations of this community. But also they have to admit that each member has their own

That system needs to grow and differentiate to survive, and any movement in every part of the system can challenge the role of the system. This concept shows the complexity to work on this field, but it opens the possibility to understand why people suffer and in the meantime can have some illness or even if nothing can be

Life is very complex; we deal with changes in our body, during the time and with

Every system has roles that must be assumed by their members, and as long it is well divided, it will work more easily; but most of the time, this task division is unfair for some of the members, and it can create stress factors. Every member of the system has some expectations about the others members, and generally it is not clear for everyone what is expected. Members of any human group will interact based on their feelings, but also over the expectations of their counterparts, but

This is the field where a systemic professional must work. And there is much more: every person has been built based on the roles that they found early in their lives, as long as they saw the childhood of their mothers and fathers and how the adults related to each other—everyone brings these in their personality, and the

The fortress that every person possesses is based on the skills developed during the childhood: ability to feed, to bond to each other, to organize life, to be protected and to protect others, to find their own limits and to define others' limits, and how to drive their own feelings in any direction. Their learnings are essential for a person to relate with the world that surrounds them. But friendship, affection, and sexual-

It is clear that knowing about the family development allows the professional to have a better understanding about the difficulties that have been faced

the relations with our family—creating a huge challenge to adapt each one with these. But few persons are aware with these challenges. Mostly, they say that is a phase or a crisis, and they do not realize that each moment can stress the system and

the ill and illness are part of lifestyle, relations, and social conditions.

necessities and will develop according to their possibilities.

they used to understand the others by reflecting over themselves.

ability to face this challenge is the key to the family success (**Figure 1**).

**38**

by individuals and groups. And the way to describe these situations needs to be understood in order to allow a therapeutic approach and offer some paths to people to have a better life.

#### **3. The steps to working with families**

Working with families can be divided into different steps in a different way for better explanation and understanding [6]. The use of these steps depends on the given situation and the needs of each family served. The following phases can be identified schematically: association, evaluation, health education, facilitation, and reference.

#### **3.1 Family connection**

Associating with the patient and their family is a fundamental requirement for the construction of the therapeutic process that should be actively pursued. The interaction of the professional with the patient is rich when the former can respect the reality and beliefs of the latter, which is often very difficult. The reality of people's lives is very diverse and demands from the professional a careful observation not to slip into attitudes centered on their own way of seeing life and to believe in solutions based on their core of knowledge. Almost all people receive good advice when they reflect their way of seeing and feeling an item; the attitude of the professional to perceive the situations by their angle of vision can put him in confrontation with the patient and his family, leading to a break in the relationship between them.

Often the professional's lack of practice in working with families leads to the difficulty of understanding why it is necessary to meet with family groups or even to visualize the feelings of each patient. Freire [7], in one of his several texts on pedagogy, approaches in a very clear way the need for the perception of personal experiences in the construction of effective communication. For this communication to take place, it must be based on the lived reality and be of adequate complexity to the person to be reached.

The professional who intends to perform his task of promoting the health of the community where he serves should be able to seek association with patients and their families. In order for this attempt to be achieved, there are some important steps to remember:


The association is initiated when the patient brings to the professional a situation where the family (or the group with which it interacts) interferes directly or indirectly in the process. Often the role of the identified patient is compromised by a clinical or social intercurrence, necessitating adjustments in the family structure, which is a very rich moment to establish a partnership with the group.

#### **3.2 Evaluation**

Once the bond with the family has been built, it is important to evaluate it through analysis tools that allow, in a more objective way, to perceive the functioning of the group being studied. These tools seek to explain the power and decision lines of the family, their way of perceiving the health and disease process, their natural resources, and their internal and community support [8]. It is from this analysis that the intervention plan will be proposed, recognizing the belief of the family in the process of becoming ill and negotiating with it an action plan that respects their way of life.

The evaluation of the family group, a clinical task of situation analysis, allows the primary care professional to understand the ways in which the different health conditions arise, such as why alcoholism has a high family incidence or why a patient with hypertension has difficulty controlling their hypertension. Minuchin [9] describes the situation of identical twin sisters with diabetes mellitus who had unequal control of their disease; when analyzing the family relations of these girls, it is found that the one who had a bad control of the disease was the one that triangulated with the parents in their problems of relationship—whenever they fought she made a crisis in their diabetes. It is common to comment in classes on hypertension that if the patients follow the professional's guidelines, they would not have consequences of their disease, but unfortunately the hypertensive patient is very difficult to deal with. This frustrates the results even though the new medications available are highly effective.

The proper evaluation of the role that the person carrying the disease has in his/her family structure (how this illness is perceived by the various components of the group, in what things they believe or like to do) gives the professional an intervention power that increases in the proposed intervention. The use of alcohol in family rituals and their insertion into happy times said by the family lead people to have difficulty understanding it as a health hazard or to glimpse the frequent drinking situation as an initial step

**41**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

toward addiction. Any intervention that proposes to face the problem of alcoholism should consider its symbology for the target group and use the lines of force of this group

Coping with chronic diseases such as hypertension [10] should understand how the patient and his family understand the disease, translating into their language what hypertension is and how the modification of habits can influence the evolution of the process. This type of negotiation is only possible if the process of association and evaluation has occurred satisfactorily, which will allow more consistent

Among the evaluation tools that we can use in primary care, we will list some that are particularly useful, focusing briefly on its use and application. Beginning with the genogram [8, 11], which is an auxiliary graphic instrument in the identification of patterns of repetition of pathologies and behaviors, allowing a quick

The family life cycle [8, 12, 13] is another powerful tool that identifies situations where the onset of dysfunctions is more frequent. It is in the transition phases where the family is challenged to structure a new pact that stress grows, allowing the emergence of diseases. The life cycle analysis allows the family to assist in understanding the tasks that must be fulfilled in order to cross these transitions. A third instrument is the social network [14], which allows us to glimpse the support and beliefs of the family. It makes it easier to see who are the key people for the search for support and on what cultural basis we will be interacting with the family. The richness of contacts and community structures allows the search for

Fundamental Interpersonal Relations Orientations (FIRO) [8, 15] is an instrument that analyzes the family from the dimensions of inclusion, control, and intimacy. Inclusion is the starting point—what is to be understood in the levels of group structure, beliefs that provide the behavioral guidelines of the group, and the roles to be played by each member for the harmony of the group. Once included the individual develops some type of control within the group and established the type of control conditions are created for the development of intimacy. FIRO provides conditions to understand the meanings of the different processes that occur in the

There are a number of other family assessment instruments that can be used in accordance with the training and preparation of the primary care professional, and this chapter does not aim to exhaust the various instruments to exhaustively detail those mentioned. In bibliographical references, suitable material can be found to

The next step in working with families is, through proper communication, initiate a health education process that leads to the development of self-care and healthier lifestyles [6, 16]. Constructing a moment of health education and anticipation of situations that allows the family and the patient to understand the process of becoming ill and how this can impose changes and restrictions on their lives is

One of the key moments in introducing concepts of health education is when the family or the patient seeks the health team to solve a problem. At this moment, an adequate explanation about the process of becoming sick that gave rise to the demand takes the client in a very receptive situation to deal with the information. This is, in fact, one of the principles of adult education—adults only learn new

one of the central points of the professional primary health care.

knowledge when they make sense in their lives.

to obtain an adequate result in the prevention and treatment of the pathology.

and long-lasting results in the follow-up of any patient.

visualization of the actions to be developed by the study family.

solutions from the very core, creating the bases for self-care.

study group, helping in the planning of the action.

study these and other instruments.

**3.3 Health education**

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

#### *Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

toward addiction. Any intervention that proposes to face the problem of alcoholism should consider its symbology for the target group and use the lines of force of this group to obtain an adequate result in the prevention and treatment of the pathology.

Coping with chronic diseases such as hypertension [10] should understand how the patient and his family understand the disease, translating into their language what hypertension is and how the modification of habits can influence the evolution of the process. This type of negotiation is only possible if the process of association and evaluation has occurred satisfactorily, which will allow more consistent and long-lasting results in the follow-up of any patient.

Among the evaluation tools that we can use in primary care, we will list some that are particularly useful, focusing briefly on its use and application. Beginning with the genogram [8, 11], which is an auxiliary graphic instrument in the identification of patterns of repetition of pathologies and behaviors, allowing a quick visualization of the actions to be developed by the study family.

The family life cycle [8, 12, 13] is another powerful tool that identifies situations where the onset of dysfunctions is more frequent. It is in the transition phases where the family is challenged to structure a new pact that stress grows, allowing the emergence of diseases. The life cycle analysis allows the family to assist in understanding the tasks that must be fulfilled in order to cross these transitions.

A third instrument is the social network [14], which allows us to glimpse the support and beliefs of the family. It makes it easier to see who are the key people for the search for support and on what cultural basis we will be interacting with the family. The richness of contacts and community structures allows the search for solutions from the very core, creating the bases for self-care.

Fundamental Interpersonal Relations Orientations (FIRO) [8, 15] is an instrument that analyzes the family from the dimensions of inclusion, control, and intimacy. Inclusion is the starting point—what is to be understood in the levels of group structure, beliefs that provide the behavioral guidelines of the group, and the roles to be played by each member for the harmony of the group. Once included the individual develops some type of control within the group and established the type of control conditions are created for the development of intimacy. FIRO provides conditions to understand the meanings of the different processes that occur in the study group, helping in the planning of the action.

There are a number of other family assessment instruments that can be used in accordance with the training and preparation of the primary care professional, and this chapter does not aim to exhaust the various instruments to exhaustively detail those mentioned. In bibliographical references, suitable material can be found to study these and other instruments.

#### **3.3 Health education**

The next step in working with families is, through proper communication, initiate a health education process that leads to the development of self-care and healthier lifestyles [6, 16]. Constructing a moment of health education and anticipation of situations that allows the family and the patient to understand the process of becoming ill and how this can impose changes and restrictions on their lives is one of the central points of the professional primary health care.

One of the key moments in introducing concepts of health education is when the family or the patient seeks the health team to solve a problem. At this moment, an adequate explanation about the process of becoming sick that gave rise to the demand takes the client in a very receptive situation to deal with the information. This is, in fact, one of the principles of adult education—adults only learn new knowledge when they make sense in their lives.

*Family Therapy - New Intervention Programs and Researches*

the other family members participate).

family beliefs or hierarchies.

communication times.

**3.2 Evaluation**

respects their way of life.

1.The moments of contact with the patient and his family are all precious;

sometimes a relationship established over time can be broken by disrespecting

2.When it is proposed to contact a patient's family, it is often difficult to see the professional (who is not clear about why a family interview is being conducted) or the patient (who fears losing his status with the professional when

3.There are pitfalls that this type of intervention can easily expose the professional: family members try to triangulate with the professional, lateralization of communication with one of the family members, the use of language inappropriate for that family group, and disrespect to the group hierarchy and their

4.The association with the patient and his/her family is the key to making primary health care no longer just a health model, a fad, but actually promoting

The association is initiated when the patient brings to the professional a situation where the family (or the group with which it interacts) interferes directly or indirectly in the process. Often the role of the identified patient is compromised by a clinical or social intercurrence, necessitating adjustments in the family structure,

Once the bond with the family has been built, it is important to evaluate it through analysis tools that allow, in a more objective way, to perceive the functioning of the group being studied. These tools seek to explain the power and decision lines of the family, their way of perceiving the health and disease process, their natural resources, and their internal and community support [8]. It is from this analysis that the intervention plan will be proposed, recognizing the belief of the family in the process of becoming ill and negotiating with it an action plan that

The evaluation of the family group, a clinical task of situation analysis, allows the primary care professional to understand the ways in which the different health conditions arise, such as why alcoholism has a high family incidence or why a patient with hypertension has difficulty controlling their hypertension. Minuchin [9] describes the situation of identical twin sisters with diabetes mellitus who had unequal control of their disease; when analyzing the family relations of these girls, it is found that the one who had a bad control of the disease was the one that triangulated with the parents in their problems of relationship—whenever they fought she made a crisis in their diabetes. It is common to comment in classes on hypertension that if the patients follow the professional's guidelines, they would not have consequences of their disease, but unfortunately the hypertensive patient is very difficult to deal with. This frustrates the results even though the new medications available are highly effective. The proper evaluation of the role that the person carrying the disease has in his/her family structure (how this illness is perceived by the various components of the group, in what things they believe or like to do) gives the professional an intervention power that increases in the proposed intervention. The use of alcohol in family rituals and their insertion into happy times said by the family lead people to have difficulty understanding it as a health hazard or to glimpse the frequent drinking situation as an initial step

an improvement in the health and life of the communities served.

which is a very rich moment to establish a partnership with the group.

**40**

At this stage, it is necessary to remember that culture is not something learned only in schools, but the living and doing of the population are also expressions of it, and that to perceive this culture is the best way to promote any change that is intended to develop. The limit is given by the community itself, which has its parameters and beliefs, on which the professional should work. In order to promote any change, it is necessary to level the information to the customer's perception capacity, help him to perceive the situation, allow him to take the step of growth, and only then provide new data or present them with greater complexity. Health professionals are often seen blaspheming the community for not following their guidelines and thus not improving their health status. These professionals forget that it is not the community's lack of capacity to listen to them that hinders them but their own inability to give meaning to the information they wish to convey.

Working health education is the initial step for the community and its sick members to change their focus and habits in dealing with illness or risk situations to get sick. Since it implies a change of habits and attitudes, this education must be based on the history and experience of the people that one wishes to benefit. This is one of the fundamental principles of "working with families," because the basic goal is to help them find their ways and promote healthier lifestyles. The strategy of this education is to pay attention to the information that the community brings us, valuing the "tips" that are said in a veiled way and respecting the power lines of the community. If, for reasons of lack of training or fears of going into certain subjects, these moments are lost, the opportunity to provide alternatives is lost. Not realizing influential people in the community and how they see and deal with health issues will often lead to opposition from the proposals put forward. The correlation of forces, in most cases, is unfavorable to health teams.

#### **3.4 Facilitation**

Another basic element of working with families is the facilitation of communication among their members, a task that requires an adequate understanding of the family hierarchy and the way the group presents itself [6]. According to systemic theory, people tend to maintain, through their negative control mechanisms, the rules and positions they occupy in the structure. This often leads to communication blockages, which form the basis of stressful situations triggering the process of becoming ill. The primary care professional, because of his unique position in the community, can identify these blocks and through programmed actions allow an adequate exchange of information and feelings that facilitate the maintenance and recovery of the family health under study.

One of the great keys to the success of communication facilitation is the FIRO tool, which allows us to perceive the structure of families and their power relations and exchanges of feelings. With this knowledge, it is possible to identify the allies and impediments for communication to flow, as well as the determinants for the perpetuation of pathogenic situations. Always remembering the systemic theory, communication can be stimulated by participating in the communication rings of the family, discussing the determinants of the life processes of that family group and making an arc of reflection in which they perceive where they come from, where they are, and where they will go. This arc of communication projects the family a sense of unity and direction, allowing the health team to be valued as a link to foster family growth, gaining credibility and efficiency in health promotion.

Communication in situations of illness or conflict requires the primary care professional to take care of the perception of feelings of guilt and the situations of balance that the group presents. An interesting strategy may be the assembly of familiar sculptures, where the team reproduces the family grouping in a stylized

**43**

relations.

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

associated with depression and the worsening of pre-existing illnesses.

way, trying to see who is leaning on whom and how the modifications can produce disturbances in the dynamics of the family group. Working with families is rewarding but requires professional dedication and commitment. The lack of perception of the family dynamics can compromise the effect of the intervention and lead to unsatisfactory results in family communication, without the expected improvement of the process. Situations of serious illness or impending death tend to put the family in a great stress, with the communication being made in a choppy way and filled with guilty silences. The work of facilitating communication enables people to explore their feelings and clarify their doubts, reducing the "silence pact" that is

The construction of this proposal involves the discussion of the framework, with respect to hierarchies and lines of communication of the family, considering their taboos and without failing to clarify the process and the causal agents of the process. Important people in the family structure, even if not belonging to the grouping, should be invited to participate in the process so that the communication reaches the desired level of exchange. This avoids the persistence of shadows in the communication, which can make it less satisfactory. The attitude of the professional during these family gatherings should be to stimulate the exchange of feelings and expectations between the components, in order to facilitate the interaction and to clarify the doubts that exist about the pathology and its progression and the avail-

In cases where it is necessary to refer the family or their patient to more complex levels, the technique of working with families also proposes a more interactive way: the reference is made explaining the reasons why the case is being addressed and which one's results are expected from this reference. In addition, contact is made with the referenced professional in order to accompany the patient and give subsidy on the situation experienced by the family during illness. This communication process increases satisfaction with referral, in addition to allowing more satisfactory results, because it gives confidence to the patient and his family, guarantees information to the reference professional, and enables the primary care professional to follow up the case on a continuous basis. This follow-up also allows for the clarification of the results obtained with the consultancy, in clearer terms to the patient and

A final characteristic well emphasized by Papp [17] is teamwork. The view of several professionals about a given situation allows a better perception of the case under study, guaranteeing a broader vision and a result closer to the aspirations of the community. The shared look glimpses the various faces of the familiar kaleidoscope, which facilitates the understanding of the process of becoming ill, increases the capacity of identification of community resources to support the case in question, and prevents pathological attitudes in the relationship of a professional with

In follow-up and family studies, understanding their natural history and patterns of illness may potentiate the action of health professionals. In this way the need arises to be able in a simple and objective way to create an instrument that shows graphically the structure and the pattern of repetition of the familiar

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

able treatment alternatives for the case.

**3.5 References**

his/her family.

the family group.

**4. Genogram**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

way, trying to see who is leaning on whom and how the modifications can produce disturbances in the dynamics of the family group. Working with families is rewarding but requires professional dedication and commitment. The lack of perception of the family dynamics can compromise the effect of the intervention and lead to unsatisfactory results in family communication, without the expected improvement of the process. Situations of serious illness or impending death tend to put the family in a great stress, with the communication being made in a choppy way and filled with guilty silences. The work of facilitating communication enables people to explore their feelings and clarify their doubts, reducing the "silence pact" that is associated with depression and the worsening of pre-existing illnesses.

The construction of this proposal involves the discussion of the framework, with respect to hierarchies and lines of communication of the family, considering their taboos and without failing to clarify the process and the causal agents of the process. Important people in the family structure, even if not belonging to the grouping, should be invited to participate in the process so that the communication reaches the desired level of exchange. This avoids the persistence of shadows in the communication, which can make it less satisfactory. The attitude of the professional during these family gatherings should be to stimulate the exchange of feelings and expectations between the components, in order to facilitate the interaction and to clarify the doubts that exist about the pathology and its progression and the available treatment alternatives for the case.

#### **3.5 References**

*Family Therapy - New Intervention Programs and Researches*

forces, in most cases, is unfavorable to health teams.

recovery of the family health under study.

**3.4 Facilitation**

At this stage, it is necessary to remember that culture is not something learned only in schools, but the living and doing of the population are also expressions of it, and that to perceive this culture is the best way to promote any change that is intended to develop. The limit is given by the community itself, which has its parameters and beliefs, on which the professional should work. In order to promote any change, it is necessary to level the information to the customer's perception capacity, help him to perceive the situation, allow him to take the step of growth, and only then provide new data or present them with greater complexity. Health professionals are often seen blaspheming the community for not following their guidelines and thus not improving their health status. These professionals forget that it is not the community's lack of capacity to listen to them that hinders them but their own inability to give meaning to the information they wish to convey. Working health education is the initial step for the community and its sick members to change their focus and habits in dealing with illness or risk situations to get sick. Since it implies a change of habits and attitudes, this education must be based on the history and experience of the people that one wishes to benefit. This is one of the fundamental principles of "working with families," because the basic goal is to help them find their ways and promote healthier lifestyles. The strategy of this education is to pay attention to the information that the community brings us, valuing the "tips" that are said in a veiled way and respecting the power lines of the community. If, for reasons of lack of training or fears of going into certain subjects, these moments are lost, the opportunity to provide alternatives is lost. Not realizing influential people in the community and how they see and deal with health issues will often lead to opposition from the proposals put forward. The correlation of

Another basic element of working with families is the facilitation of communication among their members, a task that requires an adequate understanding of the family hierarchy and the way the group presents itself [6]. According to systemic theory, people tend to maintain, through their negative control mechanisms, the rules and positions they occupy in the structure. This often leads to communication blockages, which form the basis of stressful situations triggering the process of becoming ill. The primary care professional, because of his unique position in the community, can identify these blocks and through programmed actions allow an adequate exchange of information and feelings that facilitate the maintenance and

One of the great keys to the success of communication facilitation is the FIRO tool, which allows us to perceive the structure of families and their power relations and exchanges of feelings. With this knowledge, it is possible to identify the allies and impediments for communication to flow, as well as the determinants for the perpetuation of pathogenic situations. Always remembering the systemic theory, communication can be stimulated by participating in the communication rings of the family, discussing the determinants of the life processes of that family group and making an arc of reflection in which they perceive where they come from, where they are, and where they will go. This arc of communication projects the family a sense of unity and direction, allowing the health team to be valued as a link to foster family growth, gaining credibility and efficiency in health promotion. Communication in situations of illness or conflict requires the primary care professional to take care of the perception of feelings of guilt and the situations of balance that the group presents. An interesting strategy may be the assembly of familiar sculptures, where the team reproduces the family grouping in a stylized

**42**

In cases where it is necessary to refer the family or their patient to more complex levels, the technique of working with families also proposes a more interactive way: the reference is made explaining the reasons why the case is being addressed and which one's results are expected from this reference. In addition, contact is made with the referenced professional in order to accompany the patient and give subsidy on the situation experienced by the family during illness. This communication process increases satisfaction with referral, in addition to allowing more satisfactory results, because it gives confidence to the patient and his family, guarantees information to the reference professional, and enables the primary care professional to follow up the case on a continuous basis. This follow-up also allows for the clarification of the results obtained with the consultancy, in clearer terms to the patient and his/her family.

A final characteristic well emphasized by Papp [17] is teamwork. The view of several professionals about a given situation allows a better perception of the case under study, guaranteeing a broader vision and a result closer to the aspirations of the community. The shared look glimpses the various faces of the familiar kaleidoscope, which facilitates the understanding of the process of becoming ill, increases the capacity of identification of community resources to support the case in question, and prevents pathological attitudes in the relationship of a professional with the family group.

#### **4. Genogram**

In follow-up and family studies, understanding their natural history and patterns of illness may potentiate the action of health professionals. In this way the need arises to be able in a simple and objective way to create an instrument that shows graphically the structure and the pattern of repetition of the familiar relations.

This instrument is developed in North America to facilitate the understanding of families, based on the model of the heredogram, therefore called "genogram." Its basic characteristics are to identify the structure of the family and its pattern of relationship, showing the diseases that usually occur—the repetition of the patterns of relationship and the conflicts that lead to the process of becoming ill.

The instrument, useful to the health team, can also be used as an educational factor, allowing the patient and his/her family to have a sense of the repetitions of the processes that have been occurring and how they are repeated—facilitating the insight necessary to follow up the therapeutic proposal to be developed.

As long as the family has been drawn, they can realize its connections, strengths, and the pitfalls presented by their history, a very useful tool to start a communication process and to build up partnership.

#### **5. Development of the family and the individual from the systemic perspective: family and individual life cycle and the impact of the illness**

The systemic perspective for individual and family development is based on the concept of the life cycle, formulated by the sociological theory of the family, where the family life cycle and the individual life cycle fit together through interrelations of circularities and recurrence.

According to Graham [2], the family systems development model emphasizes changes in the developmental cycle of the family and individual life cycle, introducing a very important perspective in understanding the events of family life.

The concepts of ecology and the modern orientation of biology comprehend these developments in an interrelational and interdependent way, building maps of intersubjective for understanding the family and its members. Graham [2] highlights an important lesson of the ecological view "that no matter how conscious we may be, and how our actions may be deliberate, our acts become a part of a pattern whose form and effect generally exceed our understanding. An important point is that if this change happens within each individual and its subsystems, it will produce second-order changes that will, in the process of intercommunication, reverberate throughout the whole system, producing a kaleidoscopic rearrangement of each member."

In the systemic perspective, family and individual relational life is mediated by the passage of time and in the biological-social-cultural-psychic-political developments and transformations arising from this complex phenomenon.

Hoffman (in Graham) [2] argues that development is not a continuous process but characterized by transformations, second-order changes, and sudden emergence of simply nonexistent, more functionally organized patterns.

Not being considered in a linear fashion, as concatenated cause and effect events, the development of the family and the individual incorporates the notion of the dynamic interrelationship and the processes of recursion and equifinality for elements that belong to complex systems.

Graham states that "The family life cycle is not a linear event, it does not begin with a phase nor end with the deaths of members of a specific generation. Indeed, because death can happen at any stage in the family life cycle, it is not an event of life cycle but a life-changing event. That is to say, death is an event that happens within the context of the life cycle and can affect its evolution profoundly" [2].

Proposals on the definition and identification of family and individual life cycles contribute to the development of understandings about bio-psycho-social-cultural events in these moments of change, with the concept of crisis as a propelling event for cycle changes.

**45**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

necessary the application of new resources for its internal restructuring.

subdivided by different authors, between 4 and 24 stages.

The energy of the crisis is understood in these evolutionary models as a propulsive force, occurring when the previously efficient adaptive mechanisms are not enough to maintain the stability of all intra- and extra-familiar movements, being

According to Wynne [18] there is a methodological problem in the study of the family life cycle, which would be to not reach an agreement on the number of stages that should be recognized. According to this author, the family life cycle has been

The interrelational versatility of the human being is an efficient destabilizer for the normalizations; in this way, every age of family and individual development presents new possibilities for solving the continuous process of belonging and individuation, perpetuating the task of maintaining and producing our personal and family histories, so that new stages and crises are redefined and localized. One of the proposals used is related to the inter- and intra-oscillations [2], between periods of family closeness, periods of naturalness and entanglement, non-problematic periods, and periods of family distancing. This author finds four oscillations during life about events in an individual's development: birth, child-

It also emphasizes that from the perspective of the family as a system, it understands these oscillations as having the function of providing a basis for the practice of intimacy relations and ego updates, in experiencing different levels of maturity

Another proposal is the one used by Monica McGoldrick and Bety Carter [12], emphasizing the importance of a growing and integrative expansion of cultural-social-politicalgender-racial differences in the understanding and manipulation of the life-cycle concept. "We are born into families, our first relationships, our first group, our first experience with the world, happen to and through our families, we develop, grow and hope to die within our family context. a socio-political culture, takes shape and movement involved in the matrix of the family life cycle." McGoldrick and Carter [12], p. 1.

The authors understand the phases of the American family: becoming an adult, leaving the house, becoming a couple, family with young children, transformation of the family during adolescence, casting the children and moving on, and families in the late stage. Each of these events is accompanied by emotional processes characteristic of their transition and by expected developments for the second-order

Galano [19] proposes the understanding of the family and individual life cycle through complex epistemology, taking into account differences and regularities, promoting the idea of dialogic experiences with family and individual events and

In this way, it uses the intergenerational, multidimensional, and multicontextual contingencies for the management of the family and individual life cycle with all its

"Intergenerational because the evolution of the family interferes and disrupts all members, both the nuclear family that is being constituted and the family of origin of the couple. Pluridimensional because functions, roles, values, feelings are subject to change and these do not always occur in the same way at the same time. The moments of passage from one stage to another face conflicts of interest, both 'within' members and 'among' family members. Cultural, religious, moral, racial,

In a study that is closer to our Brazilian reality, which is so rich in values and cultural characteristics, the research carried out by Cerveny and Berthoud [20], recognizing the singularities of our Brazil, makes a cut for the study of the life cycle

and in the different tasks that the individual develops in the family.

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

hood, adolescence, and adulthood.

changes necessary for family development.

ethical, socio-economic contexts". Galano [19], p. 223

by the middle-class family of São Paulo.

their significant pluricontexts.

constituent elements.

#### *Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

The energy of the crisis is understood in these evolutionary models as a propulsive force, occurring when the previously efficient adaptive mechanisms are not enough to maintain the stability of all intra- and extra-familiar movements, being necessary the application of new resources for its internal restructuring.

According to Wynne [18] there is a methodological problem in the study of the family life cycle, which would be to not reach an agreement on the number of stages that should be recognized. According to this author, the family life cycle has been subdivided by different authors, between 4 and 24 stages.

The interrelational versatility of the human being is an efficient destabilizer for the normalizations; in this way, every age of family and individual development presents new possibilities for solving the continuous process of belonging and individuation, perpetuating the task of maintaining and producing our personal and family histories, so that new stages and crises are redefined and localized.

One of the proposals used is related to the inter- and intra-oscillations [2], between periods of family closeness, periods of naturalness and entanglement, non-problematic periods, and periods of family distancing. This author finds four oscillations during life about events in an individual's development: birth, childhood, adolescence, and adulthood.

It also emphasizes that from the perspective of the family as a system, it understands these oscillations as having the function of providing a basis for the practice of intimacy relations and ego updates, in experiencing different levels of maturity and in the different tasks that the individual develops in the family.

Another proposal is the one used by Monica McGoldrick and Bety Carter [12], emphasizing the importance of a growing and integrative expansion of cultural-social-politicalgender-racial differences in the understanding and manipulation of the life-cycle concept.

"We are born into families, our first relationships, our first group, our first experience with the world, happen to and through our families, we develop, grow and hope to die within our family context. a socio-political culture, takes shape and movement involved in the matrix of the family life cycle." McGoldrick and Carter [12], p. 1.

The authors understand the phases of the American family: becoming an adult, leaving the house, becoming a couple, family with young children, transformation of the family during adolescence, casting the children and moving on, and families in the late stage. Each of these events is accompanied by emotional processes characteristic of their transition and by expected developments for the second-order changes necessary for family development.

Galano [19] proposes the understanding of the family and individual life cycle through complex epistemology, taking into account differences and regularities, promoting the idea of dialogic experiences with family and individual events and their significant pluricontexts.

In this way, it uses the intergenerational, multidimensional, and multicontextual contingencies for the management of the family and individual life cycle with all its constituent elements.

"Intergenerational because the evolution of the family interferes and disrupts all members, both the nuclear family that is being constituted and the family of origin of the couple. Pluridimensional because functions, roles, values, feelings are subject to change and these do not always occur in the same way at the same time. The moments of passage from one stage to another face conflicts of interest, both 'within' members and 'among' family members. Cultural, religious, moral, racial, ethical, socio-economic contexts". Galano [19], p. 223

In a study that is closer to our Brazilian reality, which is so rich in values and cultural characteristics, the research carried out by Cerveny and Berthoud [20], recognizing the singularities of our Brazil, makes a cut for the study of the life cycle by the middle-class family of São Paulo.

*Family Therapy - New Intervention Programs and Researches*

tion process and to build up partnership.

of circularities and recurrence.

of each member."

This instrument is developed in North America to facilitate the understanding of families, based on the model of the heredogram, therefore called "genogram." Its basic characteristics are to identify the structure of the family and its pattern of relationship, showing the diseases that usually occur—the repetition of the patterns

The instrument, useful to the health team, can also be used as an educational factor, allowing the patient and his/her family to have a sense of the repetitions of the processes that have been occurring and how they are repeated—facilitating the

As long as the family has been drawn, they can realize its connections, strengths, and the pitfalls presented by their history, a very useful tool to start a communica-

**perspective: family and individual life cycle and the impact of the illness**

The systemic perspective for individual and family development is based on the concept of the life cycle, formulated by the sociological theory of the family, where the family life cycle and the individual life cycle fit together through interrelations

According to Graham [2], the family systems development model emphasizes changes in the developmental cycle of the family and individual life cycle, introduc-

The concepts of ecology and the modern orientation of biology comprehend these developments in an interrelational and interdependent way, building maps of intersubjective for understanding the family and its members. Graham [2] highlights an important lesson of the ecological view "that no matter how conscious we may be, and how our actions may be deliberate, our acts become a part of a pattern whose form and effect generally exceed our understanding. An important point is that if this change happens within each individual and its subsystems, it will produce second-order changes that will, in the process of intercommunication, reverberate throughout the whole system, producing a kaleidoscopic rearrangement

In the systemic perspective, family and individual relational life is mediated by the passage of time and in the biological-social-cultural-psychic-political develop-

Hoffman (in Graham) [2] argues that development is not a continuous process but characterized by transformations, second-order changes, and sudden emer-

Graham states that "The family life cycle is not a linear event, it does not begin with a phase nor end with the deaths of members of a specific generation. Indeed, because death can happen at any stage in the family life cycle, it is not an event of life cycle but a life-changing event. That is to say, death is an event that happens within the context of the life cycle and can affect its evolution profoundly" [2].

Proposals on the definition and identification of family and individual life cycles contribute to the development of understandings about bio-psycho-social-cultural events in these moments of change, with the concept of crisis as a propelling event

Not being considered in a linear fashion, as concatenated cause and effect events, the development of the family and the individual incorporates the notion of the dynamic interrelationship and the processes of recursion and equifinality for

ments and transformations arising from this complex phenomenon.

gence of simply nonexistent, more functionally organized patterns.

elements that belong to complex systems.

of relationship and the conflicts that lead to the process of becoming ill.

insight necessary to follow up the therapeutic proposal to be developed.

**5. Development of the family and the individual from the systemic** 

ing a very important perspective in understanding the events of family life.

**44**

for cycle changes.

"We do not feel very comfortable when we talk about the Brazilian family, for example. The diversity of models, the breadth of the territory, the different settlements, the miscegenation, the immigrations, the monstrous socioeconomic differences that exist in our country make it difficult to the generalization of a Brazilian family. The impression is that we have many Brazilian families, which are not only defined geographically, but which suffer many other influences". Cerveny and Berthoud [20], p. 33

This author organizes the middle-class São Paulo family in four phases: the family in the acquisition phase, the adolescent family, the family in the mature phase, and the family in the last stage.

Through the temporal perspective, this instrument organizes and constructs the history of the family and the individual and makes the understandings about the changes caused by the impact of difficult circumstances experienced by the family and its members, which are better defined, according to the possibilities, functions, potentialities, and limitations of each phase.

The concept of life cycle is an extremely useful tool in understanding the intense complexity that surrounds the developing family and individual life and its interrelationships with the environment; I consider one of the central elements of the systemic theory, for understanding the developments of the family.

#### **6. Working based on the family system**

The development of the family and individual life cycle, in its interrelations with social, cultural, psychological, biological, religious, gender, and geographical circumstances, produces coping resources for crises whose purpose is to deal with the problem of disease by protecting the system of any threat in its interactive dynamics.

The understanding of family dynamics with the lens of systems theory makes it possible to understand the interactional phenomena through the Morin [21] complexity theory proposal, understanding in this way that there are several significant events in family and individual life that must be understood from a perspective of difference and belonging.

Illness is part of one of these complex family interactions, which mobilizes various sectors of our society and culture and causes intense transformations in family and individual life and throughout its life cycle.

"In the arena of physical disease, particularly chronic disease, the focus of concern is the system created by the interaction of a disease with an individual, family, or other biopsychosocial system. From a familial point of view, family system theory has to include In order to place the unfolding of chronic disease in a developmental context, it is crucial to understand the interweaving of three evolutionary lines: the disease the individual, and the family life cycle thinking in an interactive and systemic way at the interface of these three lines." Rolland [22], p. 143.

This author posits that a serious illness happens as a blow to the family and turns into a point of reference by constructing or revitalizing interactions, from this moment on. Some diseases dismantle the future predictability of family and individual life in terms of the medium and long term.

Families in their multigenerational relationships have had experiences with illness and loss and also use these experiences and beliefs as an aid and guide in coping with the disease in the present time.

In this way, clinicians and families need a more effective way to work in the field of clinical consultations, applied to the development of any disease, which makes it possible to look at the future in a more collaborative way by updating the actions developed in other moments of the cycle vital part of the family.

**47**

being threatened.

ties of adaptation.

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

"A scheme that conceptualizes chronic diseases and their relevance to psychosocial interactions is necessary, introducing into the biological world a common metalanguage that transforms or reclassifies the usual biological language. Chronic diseases need to be reconceptualized to some extent, this would organize the similarities and differences of the course of the disease, so that the type and degree of demands relevant to psychosocial research and clinical practice is highlighted in a

Rolland proposes for this planning the need for coevolutionary understanding of three structures: the disease, the individual, and the life cycles. It is necessary to consider the changes that occur, through the intercommunication between the life

In the systemic understanding of this model, there is an interaction between the structures, the disease, the individual, and the family life cycle. Two main concepts are important for a more objective understanding of this interaction: the life cycle

By structure of life, Rolland understands as being those underlying patterns that are taught and form the family, the way they live and how does the family function at any point in the life cicle. Its main components include profession, love affairs, marriages in the family, functions coordinated by the family in various social situations, relationships between individuals and individuals with themselves, and the helper functions. The family life structure forms a barrier between the family and its members and the environment governing and mediating their relationships.

The structure of life is present throughout the life cycle and attaches importance

The key issue is that there is the notion of development in the life cycle sequence, including individual, family, and disease structure. This will have great influence of

To systematically think about the interface of these three lines of development, a common language and the organization of some concepts to be applied are neces-

Two main steps are based on this model: (1) The need for a bridge between the biomedical and psychosocial worlds, a language that allows the chronic disease to be characterized in terms of psychosocial and longitudinal, and each of these conditions has specific characteristics and during the vital cycle appears with different demands.

Rolland believes that a major impact on the relational life of the couple and their lives occurs in the event of a chronic illness. It proposes the family systemic model for work with diseases in interface with families and individuals. It is also a preventive work, which offers a framework for assessment, intervention, and support for families who are involved in the problem of chronic disease and living conditions

This model is based on the systemic interaction between family and disease throughout the time. A good relationship between the demands of the disease and the family style of functioning and capacity building of the family are important determinants for the success or the location of dysfunctional resources and difficul-

Rolland points to the interface scheme between chronic disease and family and states that the variation of family conditions include the family and individual life cycles, the relationship with the life cycle and the stages of the disease, multigenerational legacies referring to the disease and loss, and the belief system. Not believing that it is possible to understand all the factors that compose the chronic disease problem and the family life cycle through the medical model emphasizes the intense

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

more useful way." Rolland [22], p. 145

cycles in the family and individual life.

already discussed above and the structure of life.

to significant events during the changes required in each phase.

sary, considering the three structures simultaneously.

importance of the social context of diseases and disabilities.

the cultural, socioeconomic, gender, ethical and racial diversity context.

(2) Need to think simultaneously about family and individual development.

#### *Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

"A scheme that conceptualizes chronic diseases and their relevance to psychosocial interactions is necessary, introducing into the biological world a common metalanguage that transforms or reclassifies the usual biological language. Chronic diseases need to be reconceptualized to some extent, this would organize the similarities and differences of the course of the disease, so that the type and degree of demands relevant to psychosocial research and clinical practice is highlighted in a more useful way." Rolland [22], p. 145

Rolland proposes for this planning the need for coevolutionary understanding of three structures: the disease, the individual, and the life cycles. It is necessary to consider the changes that occur, through the intercommunication between the life cycles in the family and individual life.

In the systemic understanding of this model, there is an interaction between the structures, the disease, the individual, and the family life cycle. Two main concepts are important for a more objective understanding of this interaction: the life cycle already discussed above and the structure of life.

By structure of life, Rolland understands as being those underlying patterns that are taught and form the family, the way they live and how does the family function at any point in the life cicle. Its main components include profession, love affairs, marriages in the family, functions coordinated by the family in various social situations, relationships between individuals and individuals with themselves, and the helper functions. The family life structure forms a barrier between the family and its members and the environment governing and mediating their relationships.

The structure of life is present throughout the life cycle and attaches importance to significant events during the changes required in each phase.

The key issue is that there is the notion of development in the life cycle sequence, including individual, family, and disease structure. This will have great influence of the cultural, socioeconomic, gender, ethical and racial diversity context.

To systematically think about the interface of these three lines of development, a common language and the organization of some concepts to be applied are necessary, considering the three structures simultaneously.

Two main steps are based on this model: (1) The need for a bridge between the biomedical and psychosocial worlds, a language that allows the chronic disease to be characterized in terms of psychosocial and longitudinal, and each of these conditions has specific characteristics and during the vital cycle appears with different demands. (2) Need to think simultaneously about family and individual development.

Rolland believes that a major impact on the relational life of the couple and their lives occurs in the event of a chronic illness. It proposes the family systemic model for work with diseases in interface with families and individuals. It is also a preventive work, which offers a framework for assessment, intervention, and support for families who are involved in the problem of chronic disease and living conditions being threatened.

This model is based on the systemic interaction between family and disease throughout the time. A good relationship between the demands of the disease and the family style of functioning and capacity building of the family are important determinants for the success or the location of dysfunctional resources and difficulties of adaptation.

Rolland points to the interface scheme between chronic disease and family and states that the variation of family conditions include the family and individual life cycles, the relationship with the life cycle and the stages of the disease, multigenerational legacies referring to the disease and loss, and the belief system. Not believing that it is possible to understand all the factors that compose the chronic disease problem and the family life cycle through the medical model emphasizes the intense importance of the social context of diseases and disabilities.

*Family Therapy - New Intervention Programs and Researches*

Berthoud [20], p. 33

and the family in the last stage.

difference and belonging.

potentialities, and limitations of each phase.

**6. Working based on the family system**

and individual life and throughout its life cycle.

individual life in terms of the medium and long term.

developed in other moments of the cycle vital part of the family.

coping with the disease in the present time.

"We do not feel very comfortable when we talk about the Brazilian family, for example. The diversity of models, the breadth of the territory, the different settlements, the miscegenation, the immigrations, the monstrous socioeconomic differences that exist in our country make it difficult to the generalization of a Brazilian family. The impression is that we have many Brazilian families, which are not only defined geographically, but which suffer many other influences". Cerveny and

This author organizes the middle-class São Paulo family in four phases: the family in the acquisition phase, the adolescent family, the family in the mature phase,

Through the temporal perspective, this instrument organizes and constructs the history of the family and the individual and makes the understandings about the changes caused by the impact of difficult circumstances experienced by the family and its members, which are better defined, according to the possibilities, functions,

The concept of life cycle is an extremely useful tool in understanding the intense complexity that surrounds the developing family and individual life and its interrelationships with the environment; I consider one of the central elements of the

The development of the family and individual life cycle, in its interrelations with social, cultural, psychological, biological, religious, gender, and geographical circumstances, produces coping resources for crises whose purpose is to deal with the problem of disease by protecting the system of any threat in its interactive dynamics. The understanding of family dynamics with the lens of systems theory makes it possible to understand the interactional phenomena through the Morin [21] complexity theory proposal, understanding in this way that there are several significant events in family and individual life that must be understood from a perspective of

Illness is part of one of these complex family interactions, which mobilizes various sectors of our society and culture and causes intense transformations in family

"In the arena of physical disease, particularly chronic disease, the focus of concern is the system created by the interaction of a disease with an individual, family, or other biopsychosocial system. From a familial point of view, family system theory has to include In order to place the unfolding of chronic disease in a developmental context, it is crucial to understand the interweaving of three evolutionary lines: the disease the individual, and the family life cycle thinking in an interactive

and systemic way at the interface of these three lines." Rolland [22], p. 143. This author posits that a serious illness happens as a blow to the family and turns into a point of reference by constructing or revitalizing interactions, from this moment on. Some diseases dismantle the future predictability of family and

Families in their multigenerational relationships have had experiences with illness and loss and also use these experiences and beliefs as an aid and guide in

In this way, clinicians and families need a more effective way to work in the field of clinical consultations, applied to the development of any disease, which makes it possible to look at the future in a more collaborative way by updating the actions

systemic theory, for understanding the developments of the family.

**46**

Family experience of illness and disability is strongly influenced by the dominant culture and health system affected by this culture.

In these conditions, he cites the incidence of diseases, the course of illnesses, the question of quality of life, and several other causes of suffering as produced by social discrimination. In the less privileged groups, it states that chronic diseases may be more prevalent and may occur earlier and in a more intense way, with a more difficult course due to problems with medical care and limited access to treatments.

Due to the technological advance, one can live a lot with a chronic illness, but this situation is often not experienced in the most deprived social strata, affecting both the family's capacity to organize resources for survival in prolonged periods of care and the individual development of its members in relation to all the demands produced by the chronic disease.

There are difficulties in integrating psychosocial work with traditional health services.

Today, many families can organize social network resources to help care for people with disabling problems, but never without spending extreme energy and effort, causing significant changes in their daily lives.

Rolland proposes the construction of a psychosocial typology of the diseases, organized in such a way that it contributes so that the family and clinicians have a form of understanding and action directed toward the integration of the preventive and curative structures.

These phases take into account the idea that diseases have a very significant temporal development peculiarity, just as each phase of the life cycle brings about the necessary relationships and behaviors, in the same way the disease in its development requires the mobilization of conduits within the cycle of individual and family life before healing or dead.

The first of these phases is the onset of illness: according to Rolland, diseases can be divided into those that occur suddenly and those that appear gradually, such as Alzheimer's disease. For sudden illnesses, emotional changes and more practical behaviors are required in a very short time, requiring the family a fairly rapid mobilization in the management of skills. Families who can tolerate explosive affective discharges, flexibility in changing roles, problems solved efficiently, and using external resources have more advantages in dealing with sudden illnesses. Gradual onset diseases such as Parkinson's require a longer adjustment period.

The second phase is the course of the disease: the course of chronic diseases have three general forms of progressive development, constant or with sporadic episodes.

Progressively, the family encounters a member with a constant symptom, in which the disability occurs gradually. Rest periods are rare due to the demands of the disease. The family lives in an ongoing process of change of function and adaptation due to disease progression. Increased exhaustion and effort of caregiver members occur because of increased demand for disease symptoms, and often the inclusion of new caregivers should occur.

Family flexibility, in the sense of internal reorganization of functions and ability to use external resources, is an excellent feature.

With the constant course of the disease, the occurrence of any event is followed by a stable biological event, for example: heart attack or severe pain in the spine. After a recovery period, the chronic phase is characterized by a period defined by a deficit or limitation. Returns to phases can happen, but the individual and the families face semipermanent changes during the course of life, so the possibility of family exhaustion exists, no matter how much effort new functions demand over time.

Relapses, or acute episodes such as asthma or disk problems, are distinguished by periods of stability and acute reactions. Families may return to more stable

**49**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

and normalcy and by the uncertainty of when a new crisis will occur.

periods, but the spectrum of relapse always remains. Relapses require families to have different attitudes toward the adjustment process. The family is called to order in periods of exacerbation of crisis brought about by the disease. The tension in the family system is caused by the frequency and transition between periods of crisis

The result in these circumstances is the profound psychosocial impact that chronic, fatal, or episodic disease causes in the course of life. The most crucial factor

In the continuum of the history of the disease, there are those that do not affect the period of life as much as arthritis (at the other extreme, there are progressive and fatal diseases such as cancer metastasis) and, in the intermediate area and in a more unpredictable category, those that shorten periods of life, such as cystic fibrosis or heart attack, and those with the possibility of sudden death, such as

The major difference between these three structures for the family is the experience of anticipatory losses and the effects of these circumstances during family life. The future expectation of loss may cause difficulties in the family with the management and control of future perspectives. The family is almost always struggling between maintaining intimacy and keeping the sick member away from the

Varied, expected emotional reactions are important and can distract the family in its role of maintaining actions to solve problems that would maintain family integrity. The family, prior to the death of the sick member, or their responses to the disease situation are difficult and can lead to ill-adapted interactions, thereby withdrawing the sick member from the problem-solving space and responsibilities

Isolation of the diseased limb occurs in these situations, and in most cases this situation is related to a lack of medical management to inform the family about possible management for the continued treatment of the disease. When the loss is imminent or certain, it provides a fertility of emotional reactions and familiar verbalizations. Being able to create relationships varies between overprotection and secondary gain for the sick member. This situation is more relevant in situations of

When disability occurs, it may involve cognitive impairment such as Alzheimer's

In some diseases the disability starts less severe and can go slowly worse, which gives the family conditions to organize functions and gives the sick member participation in planning as well. Combining types of disease onset, course, outcome, degree of disability, similarities, and differences in psychosocial patterns and their

The question of uncertainties, for Rolland, refers to the degree of predictability and unpredictability of each disease, the specificity of each path, and what will be its consequences; all these doubts produce in the family often interrelationships and

For diseases with an unexpected course such as multiple sclerosis, the resources that the family can develop or already have, and their ability to adapt, especially future plans, are delayed or can be redone due to anticipatory anxiety and the

disease, sensory impairment such as blindness, impairment of movement such as paralysis, impairment in endurance such as heart disease, mutilation such as mastectomy, and conditions associated with social stigmas such as AIDS. The type and timing of disabling illness imply significant differences in the degree of family stress. The combination of one or more disabilities requires the family's intense

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

is when the disease can be a sign of fatality.

juvenile diseases such as hemophilia and diabetes.

hemophilia.

occurrences of family life.

previously obtained.

reorganization of functions.

demands are crucial to offer a good care.

constructions of ambiguous beliefs.

inconstancy of events.

#### *Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

periods, but the spectrum of relapse always remains. Relapses require families to have different attitudes toward the adjustment process. The family is called to order in periods of exacerbation of crisis brought about by the disease. The tension in the family system is caused by the frequency and transition between periods of crisis and normalcy and by the uncertainty of when a new crisis will occur.

The result in these circumstances is the profound psychosocial impact that chronic, fatal, or episodic disease causes in the course of life. The most crucial factor is when the disease can be a sign of fatality.

In the continuum of the history of the disease, there are those that do not affect the period of life as much as arthritis (at the other extreme, there are progressive and fatal diseases such as cancer metastasis) and, in the intermediate area and in a more unpredictable category, those that shorten periods of life, such as cystic fibrosis or heart attack, and those with the possibility of sudden death, such as hemophilia.

The major difference between these three structures for the family is the experience of anticipatory losses and the effects of these circumstances during family life.

The future expectation of loss may cause difficulties in the family with the management and control of future perspectives. The family is almost always struggling between maintaining intimacy and keeping the sick member away from the occurrences of family life.

Varied, expected emotional reactions are important and can distract the family in its role of maintaining actions to solve problems that would maintain family integrity. The family, prior to the death of the sick member, or their responses to the disease situation are difficult and can lead to ill-adapted interactions, thereby withdrawing the sick member from the problem-solving space and responsibilities previously obtained.

Isolation of the diseased limb occurs in these situations, and in most cases this situation is related to a lack of medical management to inform the family about possible management for the continued treatment of the disease. When the loss is imminent or certain, it provides a fertility of emotional reactions and familiar verbalizations. Being able to create relationships varies between overprotection and secondary gain for the sick member. This situation is more relevant in situations of juvenile diseases such as hemophilia and diabetes.

When disability occurs, it may involve cognitive impairment such as Alzheimer's disease, sensory impairment such as blindness, impairment of movement such as paralysis, impairment in endurance such as heart disease, mutilation such as mastectomy, and conditions associated with social stigmas such as AIDS. The type and timing of disabling illness imply significant differences in the degree of family stress. The combination of one or more disabilities requires the family's intense reorganization of functions.

In some diseases the disability starts less severe and can go slowly worse, which gives the family conditions to organize functions and gives the sick member participation in planning as well. Combining types of disease onset, course, outcome, degree of disability, similarities, and differences in psychosocial patterns and their demands are crucial to offer a good care.

The question of uncertainties, for Rolland, refers to the degree of predictability and unpredictability of each disease, the specificity of each path, and what will be its consequences; all these doubts produce in the family often interrelationships and constructions of ambiguous beliefs.

For diseases with an unexpected course such as multiple sclerosis, the resources that the family can develop or already have, and their ability to adapt, especially future plans, are delayed or can be redone due to anticipatory anxiety and the inconstancy of events.

*Family Therapy - New Intervention Programs and Researches*

nant culture and health system affected by this culture.

effort, causing significant changes in their daily lives.

treatments.

services.

produced by the chronic disease.

and curative structures.

family life before healing or dead.

inclusion of new caregivers should occur.

to use external resources, is an excellent feature.

Family experience of illness and disability is strongly influenced by the domi-

In these conditions, he cites the incidence of diseases, the course of illnesses, the question of quality of life, and several other causes of suffering as produced by social discrimination. In the less privileged groups, it states that chronic diseases may be more prevalent and may occur earlier and in a more intense way, with a more difficult course due to problems with medical care and limited access to

Due to the technological advance, one can live a lot with a chronic illness, but this situation is often not experienced in the most deprived social strata, affecting both the family's capacity to organize resources for survival in prolonged periods of care and the individual development of its members in relation to all the demands

There are difficulties in integrating psychosocial work with traditional health

Today, many families can organize social network resources to help care for people with disabling problems, but never without spending extreme energy and

Rolland proposes the construction of a psychosocial typology of the diseases, organized in such a way that it contributes so that the family and clinicians have a form of understanding and action directed toward the integration of the preventive

These phases take into account the idea that diseases have a very significant temporal development peculiarity, just as each phase of the life cycle brings about the necessary relationships and behaviors, in the same way the disease in its development requires the mobilization of conduits within the cycle of individual and

The first of these phases is the onset of illness: according to Rolland, diseases can be divided into those that occur suddenly and those that appear gradually, such as Alzheimer's disease. For sudden illnesses, emotional changes and more practical behaviors are required in a very short time, requiring the family a fairly rapid mobilization in the management of skills. Families who can tolerate explosive affective discharges, flexibility in changing roles, problems solved efficiently, and using external resources have more advantages in dealing with sudden illnesses. Gradual

The second phase is the course of the disease: the course of chronic diseases have three general forms of progressive development, constant or with sporadic episodes. Progressively, the family encounters a member with a constant symptom, in which the disability occurs gradually. Rest periods are rare due to the demands of the disease. The family lives in an ongoing process of change of function and adaptation due to disease progression. Increased exhaustion and effort of caregiver members occur because of increased demand for disease symptoms, and often the

Family flexibility, in the sense of internal reorganization of functions and ability

With the constant course of the disease, the occurrence of any event is followed by a stable biological event, for example: heart attack or severe pain in the spine. After a recovery period, the chronic phase is characterized by a period defined by a deficit or limitation. Returns to phases can happen, but the individual and the families face semipermanent changes during the course of life, so the possibility of family exhaustion exists, no matter how much effort new functions demand over time. Relapses, or acute episodes such as asthma or disk problems, are distinguished by periods of stability and acute reactions. Families may return to more stable

onset diseases such as Parkinson's require a longer adjustment period.

**48**

Families who can build long-term perspectives and jointly work with uncertainty, sustaining hope, are more prepared to avoid risks of exhaustion or dysfunction. Frequency, complexity, and efficacy of treatment, all situations involving the hospital and the cause in the patient's care, as well as the frequency and intensity of symptoms, are important issues, differing for each disease in terms of their characteristics and which should be considered from an evolutionary and systemically oriented perspective.

In most discussions about resources to fight against cancer, disability management, or agreements with how to situate the disease in everyday life, the understanding of the disease appears through a static form rather than the perception of the disease having a process over time.

For Rolland, the concept of temporal phase for each disease enables the clinician and families to think longitudinally and understand chronic disease as a process, with situations that transpire over time and with expected limits, transitions, and changing demands.

Each disease presents distinct phases, with psychosocial demands, and the development of attitudes, concerns, and tasks that require effort and changes for the family. The main themes related to the natural history of the disease can be described in three major phases: crisis, chronic, and terminal.

Crisis phase includes any symptomatic period prior to diagnosis and the initial period of readjustment after diagnosis and initiation of treatment plan. This period brings together a significant number of skills and tasks that must be developed and/ or already exist in the family and the sick member.

Rolland informs about some universal practices that must be learned to coexist with chronic disease problems: understanding and learning about coping resources for symptoms and disability, adaptation to the treatment site, and establishment of a productive working relationship with the treatment team. The family must create meaning for disease that maximizes a sense of competence. Family members must face the mourning of life they had before the disease appeared in their lives. They need to understand illness as permanent while maintaining a sense of continuity between their past and their future. They need to organize together coping resources for the eminent crisis situation. When the crisis is about to happen, they need to develop flexibility in the face of future projects and reorientation of dreams and hopes.

Chronic phase, whether long or short, is the period of the cycle between the initial diagnosis and the readjustment and construction of the family's actions for the care of the sick member, where the questions about death and terminal illness predominate. This area is marked by episodes of constant progress or episodes of change. It is the day to day with chronic illness, those difficult moments that drag on for months or years.

The family and patient must build coping reactions and/or use the strength they have in organizing permanent changes and organize attitudes and behaviors that lead to a more comfortable day-to-day life for all of their members. The family's ability to keep matters current with chronic illness is the key to living through this period. If the disease is fatal, it is a very dense, difficult period where the passing of days is slow and intense commotion. For progressive and debilitating chronic diseases, the family feels tired having to deal with an exhaustive and endless problem.

In the terminal phase, the inevitability of death becomes apparent and dominates family life. The family deals with issues of separation, death, mourning, and the question of the reconstruction of family life after the loss. A sign of good transition happens when the family succeeds in letting go, emotional opening, seizing the opportunity to share time together, talking about unfinished business, and saying goodbye. Decide with the sick person about situations or objects for the family to live better, how far medical conduct, about the death at home or at the hospice, and

**51**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

the wishes on the funeral. These conversations, in fact, should be made in advance

Rolland calls the clinical transition the transitions in the phases of illness that refer to the periods lived at each moment and its consequences and circumstances. There are periods in which the family reassesses their competence in the period prior to illness, in view of the demands of the disease in the current phase. Situations that have not been resolved during the previous phase can hinder or block transitional phases. Families and individuals may get frozen in structures that have been built in unsatisfactory survival ratio.

Each period has its specific task independent of the type of disease. Each type of

This way of understanding chronic illness and family impact, through the choice of the systemic model, produces very useful clinical implications because it facilitates understanding and intervention in families with serious health problems along with the possible psychosocial disorders that accompany these circumstances.

Rolland draws attention to the following questions related to the characteristics of the diseases: aspect at the beginning of the illness, course, results and consequences, and inability. Acute diseases require a high level of adaptation, problem solving, function reorganizations, and balanced cohesion. Under these circumstances, helping families to maximize flexibility may be an important therapeutic

Each period of a disease delineates a characteristic type of psychosocial development; each phase has the development of its own abilities. It is important for families to be informed of their successes and know how to recognize them, to maximize the continuum of adaptations in the daily life of chronic diseases. Attention to the period and its requirements helps clinicians to access family strength and vulner-

These actions clarify the treatment plan by locating family characteristics relevant to the type and stage of the disease, sharing the information with the family, and helping to build objectives in a realistic way, giving the family a sense of power in their care journey of a member with chronic disease. Producing a pedagogical interaction with the family about the important signs of the illness, and re-orienta-

Rolland advises on the conditions of the family and the resources they have available if they combine with the transition points of the life cycle of the disease. Helping to approach the illness and the person who suffers it, and to develop an

During family living with the disease situation, it is extremely important to take into account, according to Rolland, the family beliefs about the meaning of the disease for the family, the family medical plan in a crisis situation, the family's ability to conduct in-home treatments, family communication when disease-oriented, problem solving, the reorganization of function, emotional involvement, social

For Rolland, the transition phases are the most vulnerable, because previous structures of the family, individual, and disease life cycle can be reintroduced in the form of new developmental tasks, which requires greater discontinuity in interac-

Often illness and disability tend to force the process of individual and family

For example, in the period of education of children, if a disease happens at this stage, or shortly after this stage, a derailment may occur in the natural course of family development. A disease or disability in young or adolescent adults can develop relationships of extreme dependence and return the family cycle to the childhood care phase. The construction of autonomy and independence is in danger.

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

disease has specific supplementary tasks.

interaction for a more satisfactory adjustment.

tion of the objectives in the treatment if necessary.

support, and the use and feasibility of social support.

developments into transition and increased cohesion.

economic planning in terms of prevention.

tions rather than minor changes.

ability in relation to the present and future stages of the disease.

if there are progressive illnesses.

#### *Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

the wishes on the funeral. These conversations, in fact, should be made in advance if there are progressive illnesses.

Rolland calls the clinical transition the transitions in the phases of illness that refer to the periods lived at each moment and its consequences and circumstances. There are periods in which the family reassesses their competence in the period prior to illness, in view of the demands of the disease in the current phase. Situations that have not been resolved during the previous phase can hinder or block transitional phases. Families and individuals may get frozen in structures that have been built in unsatisfactory survival ratio.

Each period has its specific task independent of the type of disease. Each type of disease has specific supplementary tasks.

This way of understanding chronic illness and family impact, through the choice of the systemic model, produces very useful clinical implications because it facilitates understanding and intervention in families with serious health problems along with the possible psychosocial disorders that accompany these circumstances.

Rolland draws attention to the following questions related to the characteristics of the diseases: aspect at the beginning of the illness, course, results and consequences, and inability. Acute diseases require a high level of adaptation, problem solving, function reorganizations, and balanced cohesion. Under these circumstances, helping families to maximize flexibility may be an important therapeutic interaction for a more satisfactory adjustment.

Each period of a disease delineates a characteristic type of psychosocial development; each phase has the development of its own abilities. It is important for families to be informed of their successes and know how to recognize them, to maximize the continuum of adaptations in the daily life of chronic diseases. Attention to the period and its requirements helps clinicians to access family strength and vulnerability in relation to the present and future stages of the disease.

These actions clarify the treatment plan by locating family characteristics relevant to the type and stage of the disease, sharing the information with the family, and helping to build objectives in a realistic way, giving the family a sense of power in their care journey of a member with chronic disease. Producing a pedagogical interaction with the family about the important signs of the illness, and re-orientation of the objectives in the treatment if necessary.

Rolland advises on the conditions of the family and the resources they have available if they combine with the transition points of the life cycle of the disease. Helping to approach the illness and the person who suffers it, and to develop an economic planning in terms of prevention.

During family living with the disease situation, it is extremely important to take into account, according to Rolland, the family beliefs about the meaning of the disease for the family, the family medical plan in a crisis situation, the family's ability to conduct in-home treatments, family communication when disease-oriented, problem solving, the reorganization of function, emotional involvement, social support, and the use and feasibility of social support.

For Rolland, the transition phases are the most vulnerable, because previous structures of the family, individual, and disease life cycle can be reintroduced in the form of new developmental tasks, which requires greater discontinuity in interactions rather than minor changes.

Often illness and disability tend to force the process of individual and family developments into transition and increased cohesion.

For example, in the period of education of children, if a disease happens at this stage, or shortly after this stage, a derailment may occur in the natural course of family development. A disease or disability in young or adolescent adults can develop relationships of extreme dependence and return the family cycle to the childhood care phase. The construction of autonomy and independence is in danger.

*Family Therapy - New Intervention Programs and Researches*

oriented perspective.

changing demands.

for months or years.

the disease having a process over time.

Families who can build long-term perspectives and jointly work with uncertainty, sustaining hope, are more prepared to avoid risks of exhaustion or dysfunction. Frequency, complexity, and efficacy of treatment, all situations involving the hospital and the cause in the patient's care, as well as the frequency and intensity of symptoms, are important issues, differing for each disease in terms of their characteristics and which should be considered from an evolutionary and systemically

In most discussions about resources to fight against cancer, disability management, or agreements with how to situate the disease in everyday life, the understanding of the disease appears through a static form rather than the perception of

For Rolland, the concept of temporal phase for each disease enables the clinician and families to think longitudinally and understand chronic disease as a process, with situations that transpire over time and with expected limits, transitions, and

Each disease presents distinct phases, with psychosocial demands, and the development of attitudes, concerns, and tasks that require effort and changes for the family. The main themes related to the natural history of the disease can be

Crisis phase includes any symptomatic period prior to diagnosis and the initial period of readjustment after diagnosis and initiation of treatment plan. This period brings together a significant number of skills and tasks that must be developed and/

Rolland informs about some universal practices that must be learned to coexist with chronic disease problems: understanding and learning about coping resources for symptoms and disability, adaptation to the treatment site, and establishment of a productive working relationship with the treatment team. The family must create meaning for disease that maximizes a sense of competence. Family members must face the mourning of life they had before the disease appeared in their lives. They need to understand illness as permanent while maintaining a sense of continuity between their past and their future. They need to organize together coping resources for the eminent crisis situation. When the crisis is about to happen, they need to develop flexibility in the face of future projects and reorientation of dreams and hopes. Chronic phase, whether long or short, is the period of the cycle between the initial diagnosis and the readjustment and construction of the family's actions for the care of the sick member, where the questions about death and terminal illness predominate. This area is marked by episodes of constant progress or episodes of change. It is the day to day with chronic illness, those difficult moments that drag on

The family and patient must build coping reactions and/or use the strength they have in organizing permanent changes and organize attitudes and behaviors that lead to a more comfortable day-to-day life for all of their members. The family's ability to keep matters current with chronic illness is the key to living through this period. If the disease is fatal, it is a very dense, difficult period where the passing of days is slow and intense commotion. For progressive and debilitating chronic diseases, the family feels tired having to deal with an exhaustive and endless problem. In the terminal phase, the inevitability of death becomes apparent and dominates family life. The family deals with issues of separation, death, mourning, and the question of the reconstruction of family life after the loss. A sign of good transition happens when the family succeeds in letting go, emotional opening, seizing the opportunity to share time together, talking about unfinished business, and saying goodbye. Decide with the sick person about situations or objects for the family to live better, how far medical conduct, about the death at home or at the hospice, and

described in three major phases: crisis, chronic, and terminal.

or already exist in the family and the sick member.

**50**

Parents need to review their plans in the social sphere to organize more care in the care of the sick person. As disease occurs in certain stages of the life cycle, it is likely that this moment may suffer from an extension in its manifestation.

When the disease appears in one parent, their ability to stay in course in the development of care and interaction with their children is severely affected.

In a more serious situation, the impact of the disease is like the arrival of a new child in the family, who has special needs and will compete with the children present; this situation can cause quite significant psychosocial changes, interfering in obtaining resources for help.

The illness captures the sick parent, and his relationship with the children is compromised. In many cases the family does not have the resources to function simultaneously with the demands of the disease and with the care of the children.

Often older children are called to share responsibilities along with other family members. All of these structural changes may be familiar supportive features, and clinicians need to be careful not to pathologize these interactions.

In this way, there is an intense interaction between the characteristics of the diseases, the circumstances in which they appear in the family and individual life cycle, and the consequences affecting all involved in this context.

Severe antisocial behaviors may occur more in adolescents, in the form of reactive or more constant peaks, worsening school performance, and reactions of isolation with the pairs of friends and with the members of the family; there may also be beneficial situations such as reorganization of sibling functions, increased sense and belonging and responsibility, restructuring in family relationships for more beneficial and rewarding interactions.

Qualifying and monitoring the solutions found by families is one of the great therapeutic resources in the follow-up of families with chronic, disabling, or fatal illnesses.

#### **7. Social network**

In the same way that illness and situations of extreme family and individual vulnerability cause suffering to the person and their significant family members, these situations also cause loss of reference in the community and society.

Systemic theory comes in the rescue of all cultural (wich look at relations, communication, and believes), communitarian, social, economic, religious, experienced and transmitted by families and their members for generations, and after transformed through the creative process in actions in the world for the development of the process of living. These singularities lost during this process of paradigmatic domination are rescued and qualified by the network concept.

For Sluzki [14], the 1990s were an evil decade, a time of medicalization of emotions. The repercussions of this model will be present in a deep and continuous way in this health/hospital interface; the effort of including the practice of interlacing relationships is daily, in all dimensions of this context, from the research to the administrative area.

Sluzki [14] defines network as the sum of all relationships that an individual perceives as meaningful or differentiates them as belonging to their interrelational context. This network corresponds to the interpersonal niche of the person and contributes substantially to his own recognition as an individual and to his selfimage (**Figure 1**).

The network is formed by virtuous circles, having the function of protecting the health of the individual, and, consequently, the health of the individual maintains the social network. It is also formed by vicious circles where the presence of a family difficulty substantially affects the social network of the family and its individual

**53**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

members, a retraction in the maintenance of interactions with the significant community, and in the same way, this detachment appears in the network environment,

According to Vasconcellos [25], the network provides sustenance support for families and individuals; for this author, the network is a distinction of the observer and, in this way, constructs spaces of interventions very useful in health work, because it expands the field of observer's view of the effects and limits of team performance and includes other contexts in the planning of therapy: the families of the people being served and the resources of the community. Producing collabora-

The disease event in the individual and family life, with all the resulting multi-

"The presence of a disease especially in the case of a chronic disease, usually debilitating or isolating, has an impact on the interactions between the individual, his/her family and the wider social network through different interrelated pro-

The disease, as an event that involves crisis emergencies, causes a temporary immobilization in people's capacity to produce new relationships and to maintain relationships as usual, reducing the quality of the network and also reducing the

Sluzki [14] stresses that social support is the raison d'être of numerous selfmanagement and self-help groups of patients and families suffering from chronic physical or emotional disorders; partial hospitalization or day hospital programs contain as one of its most important components the possibility of fostering the development and consolidation of a stable network of informal relationships and the learning or relearning of the skills needed to establish, nurture, and maintain

According to Vasconcellos [25], the network reduces the stress caused by the diagnosis, increasing a cycle of healthy feedbacks, not a vicious cycle of isolation

Vasconcellos also points out that network maintenance effort is responsible for a system's resiliency capability. Work across the network values contextual and multicontextual content, qualifying differences, enabling interacting people to become learners through situations that occur between people and the reported experiences

The disease is the consequence of a series of factors, involved with people's life choices and their genetic background and living conditions [5, 15]. Communication plays a fundamental role in human relationships, and it has a fundamentally selfreferential view—and we always communicate [23]. So when the illness happens,

According to Sluzki [14], the disease has an aversive interpersonal effect, restricts the mobility of the sick person and his family, reduces the activation initiative of the social network, and reduces the possibility of generating reciprocity behaviors. A dramatic moment as a disease can generate virtuous circles in the already existing individual and family network, in the co-construction of new networks between families, sick people, health staff, and spaces in the community and society

possibility of people reaching their goal of quality of life.

composed of people with capacity both material and emotional.

and stigmatization, distancing, social asymmetry, and weakness.

interventions, alters the daily structures minimizing the maintenance of the networks of these systems, due to the social isolation produced by some diseases that diminish the interrelated possibilities affecting the health processes of the

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

occurring a process of reciprocal retraction.

tive actions in this way.

family and individual.

cesses." Sluzki [14], p. 81.

active social relationships.

of conflict resolution experienced.

**8. Evaluating a family with the FIRO model**

#### *Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

members, a retraction in the maintenance of interactions with the significant community, and in the same way, this detachment appears in the network environment, occurring a process of reciprocal retraction.

According to Vasconcellos [25], the network provides sustenance support for families and individuals; for this author, the network is a distinction of the observer and, in this way, constructs spaces of interventions very useful in health work, because it expands the field of observer's view of the effects and limits of team performance and includes other contexts in the planning of therapy: the families of the people being served and the resources of the community. Producing collaborative actions in this way.

The disease event in the individual and family life, with all the resulting multiinterventions, alters the daily structures minimizing the maintenance of the networks of these systems, due to the social isolation produced by some diseases that diminish the interrelated possibilities affecting the health processes of the family and individual.

"The presence of a disease especially in the case of a chronic disease, usually debilitating or isolating, has an impact on the interactions between the individual, his/her family and the wider social network through different interrelated processes." Sluzki [14], p. 81.

The disease, as an event that involves crisis emergencies, causes a temporary immobilization in people's capacity to produce new relationships and to maintain relationships as usual, reducing the quality of the network and also reducing the possibility of people reaching their goal of quality of life.

According to Sluzki [14], the disease has an aversive interpersonal effect, restricts the mobility of the sick person and his family, reduces the activation initiative of the social network, and reduces the possibility of generating reciprocity behaviors.

A dramatic moment as a disease can generate virtuous circles in the already existing individual and family network, in the co-construction of new networks between families, sick people, health staff, and spaces in the community and society composed of people with capacity both material and emotional.

Sluzki [14] stresses that social support is the raison d'être of numerous selfmanagement and self-help groups of patients and families suffering from chronic physical or emotional disorders; partial hospitalization or day hospital programs contain as one of its most important components the possibility of fostering the development and consolidation of a stable network of informal relationships and the learning or relearning of the skills needed to establish, nurture, and maintain active social relationships.

According to Vasconcellos [25], the network reduces the stress caused by the diagnosis, increasing a cycle of healthy feedbacks, not a vicious cycle of isolation and stigmatization, distancing, social asymmetry, and weakness.

Vasconcellos also points out that network maintenance effort is responsible for a system's resiliency capability. Work across the network values contextual and multicontextual content, qualifying differences, enabling interacting people to become learners through situations that occur between people and the reported experiences of conflict resolution experienced.

#### **8. Evaluating a family with the FIRO model**

The disease is the consequence of a series of factors, involved with people's life choices and their genetic background and living conditions [5, 15]. Communication plays a fundamental role in human relationships, and it has a fundamentally selfreferential view—and we always communicate [23]. So when the illness happens,

*Family Therapy - New Intervention Programs and Researches*

obtaining resources for help.

Parents need to review their plans in the social sphere to organize more care in the care of the sick person. As disease occurs in certain stages of the life cycle, it is

When the disease appears in one parent, their ability to stay in course in the development of care and interaction with their children is severely affected.

The illness captures the sick parent, and his relationship with the children is compromised. In many cases the family does not have the resources to function simultaneously with the demands of the disease and with the care of the children. Often older children are called to share responsibilities along with other family members. All of these structural changes may be familiar supportive features, and

In this way, there is an intense interaction between the characteristics of the diseases, the circumstances in which they appear in the family and individual life

Severe antisocial behaviors may occur more in adolescents, in the form of reactive or more constant peaks, worsening school performance, and reactions of isolation with the pairs of friends and with the members of the family; there may also be beneficial situations such as reorganization of sibling functions, increased sense and belonging and responsibility, restructuring in family relationships for

Qualifying and monitoring the solutions found by families is one of the great therapeutic resources in the follow-up of families with chronic, disabling, or fatal illnesses.

In the same way that illness and situations of extreme family and individual vulnerability cause suffering to the person and their significant family members,

Sluzki [14] defines network as the sum of all relationships that an individual perceives as meaningful or differentiates them as belonging to their interrelational context. This network corresponds to the interpersonal niche of the person and contributes substantially to his own recognition as an individual and to his self-

The network is formed by virtuous circles, having the function of protecting the health of the individual, and, consequently, the health of the individual maintains the social network. It is also formed by vicious circles where the presence of a family difficulty substantially affects the social network of the family and its individual

these situations also cause loss of reference in the community and society. Systemic theory comes in the rescue of all cultural (wich look at relations, communication, and believes), communitarian, social, economic, religious, experienced and transmitted by families and their members for generations, and after transformed through the creative process in actions in the world for the development of the process of living. These singularities lost during this process of paradigmatic domination are rescued and qualified by the network concept. For Sluzki [14], the 1990s were an evil decade, a time of medicalization of emotions. The repercussions of this model will be present in a deep and continuous way in this health/hospital interface; the effort of including the practice of interlacing relationships is daily, in all dimensions of this context, from the research to the

In a more serious situation, the impact of the disease is like the arrival of a new child in the family, who has special needs and will compete with the children present; this situation can cause quite significant psychosocial changes, interfering in

likely that this moment may suffer from an extension in its manifestation.

clinicians need to be careful not to pathologize these interactions.

cycle, and the consequences affecting all involved in this context.

more beneficial and rewarding interactions.

**7. Social network**

administrative area.

image (**Figure 1**).

**52**

a reflection is needed, "why does this happen at this moment?" "What leads to the emergence of this specific situation?" And still more the question: "how can we help this person or this family to find a better way to deal with your challenges?"

Schutz [24] in 1958 proposed the FIRO model (Fundamental Interpersonal Relations Orientation) for the study of small groups. In 1984 Doherty [24] adapts this model to systemic health care. According to Schutz the groups can be studied in three dimensions, namely, inclusion, control, and intimacy. Years later he rewrites about the method, and in 1977 he describes FIRO B—in which he develops work scales for group study.

#### **8.1 Inclusion**

When you are part of a group, the first question to be resolved is to be accepted by it; as long as we do not feel part of the group, we are going to act insecurely and generate attitudes so that they see, perceive, and recognize us. In a family this is also critical. The more I feel part and important, within the family nucleus, the more I feel free and able to fully develop within this context.

But it is not enough to be in the family; it is important that the space and the forms of communication are clear and acceptable so that I feel included. Doherty [4] raises the need to perceive what space and role we occupy within the family structure—and using Sluzki's framework [14], we can say that the more central we are within the family structure, the more knowledge we have about the rule and family designs for its members. Wilson [7] poses the issue of communication and subliminal issues—which often cloud our view of communication occurring within the family. And yet in this item, questions about how we share acts and things make the complexity of this component.

The issue of inclusion is so impotent that it is a cornerstone in the systemic structural therapy proposed by Minuchin [9]. And how does inclusion work? Before interacting in a particular group, you need to know what our space and what capacity for influence we have. A child tests boundaries uninterruptedly to find out this, teenagers question rules and limits family and adults try to assert their positions all this is inclusion, but not just this.

The agreed rules in each group are part of this component, where issues often escape the external observer and will only become apparent with systematic pursuit—family secrets, entrenched beliefs about health issues, and accepted or non-accepted behaviors. So detailing in a map of questions about what and how the person and his family perceive the health situation makes us able to better understand their positions and provides the appropriate condition to propose valid interventions. The family's communication style and the way they determine their roles and functions within the family provide a very rich material to be worked on.

#### **8.2 Control**

The second component of the FIRO model is control, and it is the second component because without knowing its space and being accepted in a certain group, it is impossible to have some type of control. The exercise of control can be done in different ways—direct and indirect—and will depend on the family structure and its power lines.

When assessing a family, the observer often has difficulty understanding the chains of command, which are exercised either by economic power, personal leadership, or structural family issues. When entering within the scope of the family, it is basic to discover how it reacts to situations of stress and of the decision processes, because the different types of control become apparent.

**55**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

Classically Wilson [8] divides the control into dominant, collaborative, and reactive. But the nuances of these components are more complex and require special attention from the observer. Dominance may be in some areas, and the way of exercising it varies greatly, with different results. The same goes for the other modes

The understanding of these behaviors shows its importance in the adhesion of the patients to the different treatments, particularly when talking about chronic disease. Dominant people within a social nucleus if they do not understand the pathology and the proposal of intervention can hinder adherence to the treatment

Some family therapy schools base their actions on this component, such as the

The third component proposed by Schutz is intimacy. When I recognize myself as part of a group, I know my place, and I have some kind of control within it; I am ready to establish exchange relationships, and I am able to share emotions and

More subtle within the work centers, the knowledge of affective relationships and loyalty is a powerful way to gain adherence and support the people to whom

Also some family therapy schools are based on this component as the humanistic

Working on it is simple. The model was designed for working with groups within social settings; the adaptation proposed by Doherty [5] and later by Wilson [8] brings the tool to the family and supports the treatment of family and support

The instrument can be used in individual care by taking a person-centered approach. In this context the approach explores the knowledge it has about the health situation and how this is influenced by its environment. How much of their autonomy is affected by the situation, who defines the searches and priorities of care and the changes and treatments to be performed. Finally with whom in the

Used in this way, the FIRO is simple and broadens the dialog, favoring adherence

In situations where changes are difficult, people have difficulty adhering to treatment or the results fall short of the goals proposed the use of a family interview

In these cases, the interviewer should listen to all members and care about absent members, or who refuses to participate is crucial because they generally play an important role within the family structure and may render the approach ineffective. An interviewer considering FIRO should listen to the family's understanding of the health situation, their beliefs, and previous experiences with similar situations. Next identify the key people in the family hierarchy—providers, tasks and spaces of each member, forms of communication, and people who are considered "scape-

At a later moment, one can seek to explore the power lines within the family, identifying who actually decides and how people collaborate or resist the proposals of people who have some control within the family. This will identify how the fam-

Example: attending a family with diabetes and the generally inadequate control generated a family interview to understand the difficulties in following the

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

and the changes of the necessary habits.

strategic school developed by Haley.

of control.

**8.3 Intimacy**

feelings.

attention is given.

for clinical interventions.

goats" of the family.

group he/she shares his/hers doubts and complaints.

with the support of the methodology can be very useful.

ily facilitates, or creates, difficulties in controlling the case.

to the treatment besides narrowing the patient doctor relationship.

school of Satir.

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

Classically Wilson [8] divides the control into dominant, collaborative, and reactive. But the nuances of these components are more complex and require special attention from the observer. Dominance may be in some areas, and the way of exercising it varies greatly, with different results. The same goes for the other modes of control.

The understanding of these behaviors shows its importance in the adhesion of the patients to the different treatments, particularly when talking about chronic disease. Dominant people within a social nucleus if they do not understand the pathology and the proposal of intervention can hinder adherence to the treatment and the changes of the necessary habits.

Some family therapy schools base their actions on this component, such as the strategic school developed by Haley.

#### **8.3 Intimacy**

*Family Therapy - New Intervention Programs and Researches*

feel free and able to fully develop within this context.

the complexity of this component.

all this is inclusion, but not just this.

scales for group study.

**8.1 Inclusion**

a reflection is needed, "why does this happen at this moment?" "What leads to the emergence of this specific situation?" And still more the question: "how can we help

When you are part of a group, the first question to be resolved is to be accepted by it; as long as we do not feel part of the group, we are going to act insecurely and generate attitudes so that they see, perceive, and recognize us. In a family this is also critical. The more I feel part and important, within the family nucleus, the more I

But it is not enough to be in the family; it is important that the space and the forms of communication are clear and acceptable so that I feel included. Doherty [4] raises the need to perceive what space and role we occupy within the family structure—and using Sluzki's framework [14], we can say that the more central we are within the family structure, the more knowledge we have about the rule and family designs for its members. Wilson [7] poses the issue of communication and subliminal issues—which often cloud our view of communication occurring within the family. And yet in this item, questions about how we share acts and things make

The issue of inclusion is so impotent that it is a cornerstone in the systemic structural therapy proposed by Minuchin [9]. And how does inclusion work? Before interacting in a particular group, you need to know what our space and what capacity for influence we have. A child tests boundaries uninterruptedly to find out this, teenagers question rules and limits family and adults try to assert their positions—

The agreed rules in each group are part of this component, where issues often

The second component of the FIRO model is control, and it is the second component because without knowing its space and being accepted in a certain group, it is impossible to have some type of control. The exercise of control can be done in different ways—direct and indirect—and will depend on the family structure and

When assessing a family, the observer often has difficulty understanding the chains of command, which are exercised either by economic power, personal leadership, or structural family issues. When entering within the scope of the family, it is basic to discover how it reacts to situations of stress and of the decision processes,

because the different types of control become apparent.

escape the external observer and will only become apparent with systematic pursuit—family secrets, entrenched beliefs about health issues, and accepted or non-accepted behaviors. So detailing in a map of questions about what and how the person and his family perceive the health situation makes us able to better understand their positions and provides the appropriate condition to propose valid interventions. The family's communication style and the way they determine their roles and functions within the family provide a very rich material to be worked on.

this person or this family to find a better way to deal with your challenges?" Schutz [24] in 1958 proposed the FIRO model (Fundamental Interpersonal Relations Orientation) for the study of small groups. In 1984 Doherty [24] adapts this model to systemic health care. According to Schutz the groups can be studied in three dimensions, namely, inclusion, control, and intimacy. Years later he rewrites about the method, and in 1977 he describes FIRO B—in which he develops work

**54**

**8.2 Control**

its power lines.

The third component proposed by Schutz is intimacy. When I recognize myself as part of a group, I know my place, and I have some kind of control within it; I am ready to establish exchange relationships, and I am able to share emotions and feelings.

More subtle within the work centers, the knowledge of affective relationships and loyalty is a powerful way to gain adherence and support the people to whom attention is given.

Also some family therapy schools are based on this component as the humanistic school of Satir.

Working on it is simple. The model was designed for working with groups within social settings; the adaptation proposed by Doherty [5] and later by Wilson [8] brings the tool to the family and supports the treatment of family and support for clinical interventions.

The instrument can be used in individual care by taking a person-centered approach. In this context the approach explores the knowledge it has about the health situation and how this is influenced by its environment. How much of their autonomy is affected by the situation, who defines the searches and priorities of care and the changes and treatments to be performed. Finally with whom in the group he/she shares his/hers doubts and complaints.

Used in this way, the FIRO is simple and broadens the dialog, favoring adherence to the treatment besides narrowing the patient doctor relationship.

In situations where changes are difficult, people have difficulty adhering to treatment or the results fall short of the goals proposed the use of a family interview with the support of the methodology can be very useful.

In these cases, the interviewer should listen to all members and care about absent members, or who refuses to participate is crucial because they generally play an important role within the family structure and may render the approach ineffective. An interviewer considering FIRO should listen to the family's understanding of the health situation, their beliefs, and previous experiences with similar situations. Next identify the key people in the family hierarchy—providers, tasks and spaces of each member, forms of communication, and people who are considered "scapegoats" of the family.

At a later moment, one can seek to explore the power lines within the family, identifying who actually decides and how people collaborate or resist the proposals of people who have some control within the family. This will identify how the family facilitates, or creates, difficulties in controlling the case.

Example: attending a family with diabetes and the generally inadequate control generated a family interview to understand the difficulties in following the

guidelines regarding lifestyle habits and therapeutics. It became obvious that the family greatly valued the use of the drugs that were used properly, with the consumption monitored by the team as planned. But the person who made purchases and took responsibility for food had a low understanding of what diabetes would be, as well as feeding a person with the disease. During the approach it was made clear to all that food would always have sugars and that the fractionation of the diet and the use of foods with slower release of sugar would be fundamental to the control. The target patient of the activity put how much she felt taken care of by the relatives, who did many things for her—but also did not perceive clearly the dietary error. After the interview there was a 30% reduction in glycemic levels, without the family losing the affective link and improving the understanding of the health team's concerns about the patient on the screen.

The use of FIRO can be taken to improve care by inviting people, families, or groups to talk about the dimensions in which the instrument was studied—people are invited to talk about themselves and to perceive themselves within their context. This improves understanding of the processes and by itself is already therapeutic.

The professional who understands the dimensions of belonging, control, and intimacy can transform the dialog with patients in a process of growth and review of situations, which makes the interview rich and motivating. The key question is, the perception of how central to each element is how your life is organized, how it perceives the interpersonal relationships in your group, and how it influences their lives.

For most people, exchanging information in a quiet dialog can reshape their sufferings and difficulties without requiring any intervention by the therapist—only the flow of dialog and openness to encourage people to talk about their expectations and difficulties within the relationship.

By understanding the concept of a biopsychosocial model, it is clear that a group interactions are an important part of the health-disease process. By establishing a thoughtful conversation, people begin their journey of recovery.

#### **9. Conclusion**

A family system approach is now a concept that is well developed and, despite its challenging way to think, allows the health professional to have an open, broad comprehension of the context. Based on that, it is possible to help people to better understand their situation and find a new path to have a healthier life.

Most of the time, the blindness attached to a lack of comprehension of the facts linked to any situation is the cause of suffering and may be one of the key points to the development of any ill that will emerge in the future.

This approach to families turns blindness into understanding and can be a pathway for the development of new languages among families and health professionals. New indicators of well-being would be recognized by increasing the quality of life of families and communities.

**57**

**Author details**

provided the original work is properly cited.

Hamilton Lima Wagner1,2\* and Tania Dalallana3

2 Family and Community Medicine of Curitiba, Curitiba, Brazil

1 Health System of Curitiba, Curitiba, Brazil

3 Federal University of Paraná, Curitiba, Brazil

\*Address all correspondence to: hamiltonw@uol.com.br

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

#### **Author details**

*Family Therapy - New Intervention Programs and Researches*

the patient on the screen.

and difficulties within the relationship.

therapeutic.

their lives.

**9. Conclusion**

of families and communities.

guidelines regarding lifestyle habits and therapeutics. It became obvious that the family greatly valued the use of the drugs that were used properly, with the consumption monitored by the team as planned. But the person who made purchases and took responsibility for food had a low understanding of what diabetes would be, as well as feeding a person with the disease. During the approach it was made clear to all that food would always have sugars and that the fractionation of the diet and the use of foods with slower release of sugar would be fundamental to the control. The target patient of the activity put how much she felt taken care of by the relatives, who did many things for her—but also did not perceive clearly the dietary error. After the interview there was a 30% reduction in glycemic levels, without the family losing the affective link and improving the understanding of the health team's concerns about

The use of FIRO can be taken to improve care by inviting people, families, or groups to talk about the dimensions in which the instrument was studied—people are invited to talk about themselves and to perceive themselves within their context. This improves understanding of the processes and by itself is already

The professional who understands the dimensions of belonging, control, and intimacy can transform the dialog with patients in a process of growth and review of situations, which makes the interview rich and motivating. The key question is, the perception of how central to each element is how your life is organized, how it perceives the interpersonal relationships in your group, and how it influences

For most people, exchanging information in a quiet dialog can reshape their sufferings and difficulties without requiring any intervention by the therapist—only the flow of dialog and openness to encourage people to talk about their expectations

By understanding the concept of a biopsychosocial model, it is clear that a group interactions are an important part of the health-disease process. By establishing a

A family system approach is now a concept that is well developed and, despite its challenging way to think, allows the health professional to have an open, broad comprehension of the context. Based on that, it is possible to help people to better

Most of the time, the blindness attached to a lack of comprehension of the facts linked to any situation is the cause of suffering and may be one of the key points to

This approach to families turns blindness into understanding and can be a pathway for the development of new languages among families and health professionals. New indicators of well-being would be recognized by increasing the quality of life

thoughtful conversation, people begin their journey of recovery.

understand their situation and find a new path to have a healthier life.

the development of any ill that will emerge in the future.

**56**

Hamilton Lima Wagner1,2\* and Tania Dalallana3

1 Health System of Curitiba, Curitiba, Brazil

2 Family and Community Medicine of Curitiba, Curitiba, Brazil

3 Federal University of Paraná, Curitiba, Brazil

\*Address all correspondence to: hamiltonw@uol.com.br

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Khun TS. A estrutura das revoluções cintíficas. 5th ed. São Paulo: Perspectivas; 1997

[2] Lee C-G. A developmental model for family systems. Family Process. 1985;**24**:139-150

[3] Grassano S et al. Abordagem Sistêmico Integrativa. Curitiba: CD Rom—Chaim; 1996

[4] Stewart M et al. Medicina centrada na pessoa. 2nd ed. Porto Alegre: Artmed; 2010

[5] Cristiee-Seely J. Working with Families in Primary Care. New York: Kellogg's Foundation; 1984

[6] Talbot YR. Family System Medicine. Toronto: Publicola Geg'd; 1991

[7] Freire P. Pedagogia da Esperança. Rio de Janeiro: Paz e Terra; 1992

[8] Wilson L. Trabalhando com famílias livro de trabalho para residentes. Curitiba: Secretaria Municipal de Saúde de Curitiba; 1996

[9] Minuchin S. Famílias Funcionamento & Tratamento. Porto Alegre: Artes Médicas; 1990

[10] Wagner ABP, Wagner HL, Talbot Y, Carmo AE. Aplicação de Rede Social no Manejo da Hipertensão. Vol. 1. Curitiba: RBMFC; 2004

[11] Wagner HL et al. Ferramenta de Descrição da Família e dos Seus Padrões de Relacionamento—Genograma—Uso em Saúde da Família. Vol. 57(1/2). Curitiba: Revista Médica do Paraná.; 1999. pp. 28-33

[12] McGoldrick M, Carter B, editors. The Expanded Family Life Cycle: Individual, Family and Social Perspectives, USA. 3rd ed. Allyn & Bacon; 1999

[13] Wagner HL et al. Ferramenta de Avaliação Para Situações Indefinidas e Manobras Preventivas em Saúde da Família—Ciclo de Vida das Famílias. Vol. 57(1/2). Curitiba: Revista Médica do Paraná.; 1999. pp. 22-27

[14] Sluzki CE. La Red Social: Frontera de la practica sistemica. Barcelona: Gedisa; 1996

[15] Wagner HL. Avaliação Familiar. PROMEF. Artmed. Ciclo 7. Vol. 2. 2012

[16] Freire P. Pedagogia da Autonomia. 43rd ed. São Paulo: Paz e Terra; 2011

[17] Papp P. O Processo de Mudança. Porto Alegre: Artes Médicas; 1991

[18] Wynne L et al. Professional Politics and the Concepts of Family Therapy, Family Consultation And Sistems Consultation. Vol. 26. Fam Pro; 1988

[19] Galano MH. O ciclo vital da família uma visão complexa. In: Perspectivas Psicodinâmicas em Psiquiatria. São Paulo: Lemos; 2001

[20] Cerveny MOC, Berthoud EMC. Família e Ciclo Vital: Nossa realidade em pesquisa. São Paulo: Casa do Psicólogo; 1997

[21] Morin E. Introdução ao Pensamento Complexo. Porto Alegre; 1999

[22] Rolland J, Families S, editors. Illness and disability. An Integrative Treatment Model. New York: Basic Books; 1994

[23] Watzlawick P, Beavin JH, Jackson DD. Pragmática da Comunicação Humana. São Paulo: Cultrix; 1973

[24] McDaniel SH et al. Terapia Familiar Médica. Porto Alegre: Artes Médicas; 1994

**59**

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach…*

*DOI: http://dx.doi.org/10.5772/intechopen.84582*

[25] Esteves de Vasconcellos MJ. De sistemas, redes e paradigmas. In: Anais do III Congresso Brasileiro de Terapia Familiar: O individuo, a família e as redes sociais na virada do século. Rio de Janeiro: Asociação Brasileira de Terapia

Familiar e ATF-RJ; 1998

*Family Therapy: New Intervention Programs and Researches: Systemic Family Approach… DOI: http://dx.doi.org/10.5772/intechopen.84582*

[25] Esteves de Vasconcellos MJ. De sistemas, redes e paradigmas. In: Anais do III Congresso Brasileiro de Terapia Familiar: O individuo, a família e as redes sociais na virada do século. Rio de Janeiro: Asociação Brasileira de Terapia Familiar e ATF-RJ; 1998

**58**

*Family Therapy - New Intervention Programs and Researches*

[13] Wagner HL et al. Ferramenta de Avaliação Para Situações Indefinidas e Manobras Preventivas em Saúde da Família—Ciclo de Vida das Famílias. Vol. 57(1/2). Curitiba: Revista Médica do

[14] Sluzki CE. La Red Social: Frontera de la practica sistemica. Barcelona:

[15] Wagner HL. Avaliação Familiar. PROMEF. Artmed. Ciclo 7. Vol. 2.

[16] Freire P. Pedagogia da Autonomia. 43rd ed. São Paulo: Paz e Terra; 2011

[17] Papp P. O Processo de Mudança. Porto Alegre: Artes Médicas; 1991

[18] Wynne L et al. Professional Politics and the Concepts of Family Therapy, Family Consultation And Sistems Consultation. Vol. 26. Fam Pro; 1988

[19] Galano MH. O ciclo vital da família uma visão complexa. In: Perspectivas Psicodinâmicas em Psiquiatria. São

[20] Cerveny MOC, Berthoud EMC. Família e Ciclo Vital: Nossa realidade em pesquisa. São Paulo: Casa do Psicólogo;

[21] Morin E. Introdução ao Pensamento

Complexo. Porto Alegre; 1999

[22] Rolland J, Families S, editors. Illness and disability. An Integrative Treatment Model. New York: Basic

[23] Watzlawick P, Beavin JH, Jackson DD. Pragmática da Comunicação Humana. São Paulo: Cultrix; 1973

[24] McDaniel SH et al. Terapia Familiar Médica. Porto Alegre: Artes Médicas;

Paulo: Lemos; 2001

1997

Books; 1994

1994

Paraná.; 1999. pp. 22-27

Gedisa; 1996

2012

[1] Khun TS. A estrutura das

Perspectivas; 1997

**References**

1985;**24**:139-150

Rom—Chaim; 1996

Artmed; 2010

Curitiba; 1996

Médicas; 1990

RBMFC; 2004

1999. pp. 28-33

ed. Allyn & Bacon; 1999

revoluções cintíficas. 5th ed. São Paulo:

[2] Lee C-G. A developmental model for family systems. Family Process.

[4] Stewart M et al. Medicina centrada na pessoa. 2nd ed. Porto Alegre:

[6] Talbot YR. Family System Medicine.

[7] Freire P. Pedagogia da Esperança. Rio

[8] Wilson L. Trabalhando com famílias livro de trabalho para residentes. Curitiba:

[9] Minuchin S. Famílias Funcionamento & Tratamento. Porto Alegre: Artes

[10] Wagner ABP, Wagner HL, Talbot Y, Carmo AE. Aplicação de Rede Social no Manejo da Hipertensão. Vol. 1. Curitiba:

[11] Wagner HL et al. Ferramenta de Descrição da Família e dos Seus Padrões de Relacionamento—Genograma—Uso em Saúde da Família. Vol. 57(1/2). Curitiba: Revista Médica do Paraná.;

[12] McGoldrick M, Carter B, editors. The Expanded Family Life Cycle: Individual, Family and Social Perspectives, USA. 3rd

[5] Cristiee-Seely J. Working with Families in Primary Care. New York:

Kellogg's Foundation; 1984

Toronto: Publicola Geg'd; 1991

de Janeiro: Paz e Terra; 1992

Secretaria Municipal de Saúde de

[3] Grassano S et al. Abordagem Sistêmico Integrativa. Curitiba: CD

**61**

Section 2

Improving Children's

Future

### Section 2
