3 Essential Ingredients for Effective Family Therapy

One of the challenges I faced during my training as a psychologist was determining how to improve client behavior between sessions in order to optimize treatment outcomes.

Clients often presented with stressful family relationships, relationships that seemed to limit therapeutic progress. I wanted to help my clients as individuals, but I also understood that they did not exist within vacuums. In family therapy, I was able to help clients appreciate how family dynamics and communication styles are important factors in achieving their individual behavioral health goals.  

Family therapy also extended my therapeutic reach beyond the individual and beyond the one hour that we had together each week.

Families can become frustrated when they feel stuck in a cycle. They continue to argue, isolate, or feel misunderstood. It can be challenging for families to ask for help, but therapists can provide unique perspectives within a setting that allows each family member to feel heard.

Therapy can aid families in getting out of the cycle and beginning to move forward together. A functional family system consists of many parts, but I have found three consistent patterns regarding communication, boundaries, and trust.

Communication

Communication, or lack thereof, is often where the conflict begins.  

The therapist should attend to it early in the therapy process. Many families have complaints about how communication is occurring between members, which makes this a good place to start the process. These complaints are commonly shared at the beginning of therapy. “She never listens.” “He is always yelling at me.” “Mom doesn’t get it.”  

To understand how the system communicates, the therapist should evaluate how communication occurs between family members and how they react to one another. Once communication patterns are understood and presented to the family, it can be easier to promote change in how the family articulates ideas to one another.

One helpful strategy here is for the therapist to point out strengths in communication on which the family can build when they are attempting to change the unhelpful patterns. Emphasizing strengths allows the family to feel like they have some tools with which to move forward. This method can afford the family the opportunity to begin experiencing change and the benefits of therapy starting in the first session.

Communication is generally simple for families to become aware of as the therapist gives examples of harmful patterns that are evident in session. A family member who presents as defensive or guarded can make this process difficult as they may not be willing to accept the harmful interactions to which they contribute. As therapy goes on and they begin to feel that therapy is a safe place, those defenses will diminish.

Next, the therapist should look deeper into what the communication patterns mean for the family. Some examples of this might include:

• Dynamics – What roles do members fill in the system?
• Power – What is the hierarchy or pecking order?
• Rules – What topics are off limits?
• Coping – What are the self-soothing or recovery behaviors?

These themes are imperative in understanding the long-standing nature of the system. When the therapist focuses on communication, the family’s ability to gain systemic insight is increased.

These skills are vital, as there are many factors that can lead individuals in the family to be unable to complete therapy tasks. Some examples might include:

• Misunderstanding the material
• Experiencing low motivation
• Feeling overwhelmed or disorganized
• Feeling fearful of change
• Continuing old habits

It can be helpful if the therapist focuses on how the communication style is related to the presenting problem that the family brings in. This understanding can also help the family to alleviate the distress as they move toward the treatment goal.

Boundaries

Unhealthy family systems tend to either neglect or overuse boundaries.  

Boundaries are important within any family, as these rules are linked with expectations. Often, family members struggle because the expectations in the home do not meet the needs of the individual or the system. Healthy boundaries keep family members in the roles with which they are comfortable, as well as prevent assignment of role confusion and inappropriate responsibilities (i.e., parentified child).  

Role confusion can also lead to boundary issues. The therapist can learn how the current boundaries are working for some family members and not others, and discuss healthier alternatives with the family. Much like buildings, family systems need structure to maintain soundness.  

Some important structural boundaries are between parent and child, as well as between parents.  In the parent and child relationships, the boundaries set by the parents set the stage for how the child is expected to behave. Dysfunction can occur when the parents set unhealthy or unreachable expectations for the child, or when the child does not behave according to the rules set by the family.

This can also be made more complex in single-parent homes. In the relationship between the parents, there can be an array of struggles depending on whether they are together or not and what expectations they have of each other as co-parents.

The therapist can assist the family in discussing the boundaries they have set for themselves and for one another, and if these are fair or healthy for the family. As the therapist continues to build structure and regulate healthy boundaries, the system can begin to regain function.  

Trust

In therapy, we rely heavily on trust. To do so, we use perhaps the most essential, and most well-known, ingredient of empathic understanding.

In family therapy, this includes empathy from the therapist as well as between family members.  The therapist can lead family members to this by asking them to take the perspective of other family members. Simple questions — “It sounds like you were angry when that happened. I wonder if you can guess how it made your sister feel?” — can promote theory of mind and emotional connection.

As family members become more comfortable exposing their vulnerabilities to one another, they begin to understand one another and develop trust. Once family members can understand why the other members are behaving the way they are, the system begins to repair itself. The therapist can then focus on deeper issues in the system and promote long-term stability.

Bonus Ingredient: Fun!

How does the family enjoy down-time? Do the members retreat to their bedrooms to read or watch television, or are there activities the whole family enjoys together?  

Many families drift apart over time, and the systemic relationship goes cold. Drawing out previously enjoyed family activities and recommending them as intervention gives the family an opportunity to have fun together again. For instance, the therapist may assign the homework of watching a movie together and eating popcorn at least once a week.