Prepared by: Alecs Smith

 A psychotherapy that involves family

members in addition to the identified patient,
and/or explicitly attends to the interactions
among family members (Pinsof and Wyne
1995).
1. Meanings are in words.
2. Communication is a verbal process.
3. Telling is communicating.
4. Communication will solve all our problems.
5. Communication is a good thing.
6. The more communication, the better.
7. Communication can break down.
8. Communication is a natural ability.
 The diagnostic family interview is an
invaluable tool to assist the psychiatrist in the
development of diagnostic and therapeutic
goals.
 The diagnostic interview can take place as the
initial contact with the family, regardless of
the nature of the presenting problem; it can
be part of the comprehensive assessment of a
symptomatic child or adult; or it can occur
when therapeutic efforts of any type are
partially or totally ineffective.
 The goals of clinicians vary and may
include:

◦ Identifying family and individual variables that

may play the decisive role in shaping the behavior
of a problematic family member.
◦ Assessing the adequacy of family functioning,
structure, and development according to the
family life cycle; and

◦ Conducting an initial family treatment session,

when the necessity of such course has been
recognized by the family or by the referral source.
◦ The clinician acts as a host to the family
according to the prevailing customs.
◦ The family is put at ease by engaging in mutual
introductions, asking the family to introduce
themselves by name, matching the names with
family members, and inviting them to make
themselves comfortable.
[Link] family should be provided with adequate
seating, preferably in a conversational living room
arrangement, and with play material, table, and
chairs for young children.
 Zilbach (1986) recommends that the clinician
crouch down to establish eye – to – eye contact
with young children and be alert to the possibility
that some young children may be afraid of
handshakes or physical touching.
 A few minutes may be spent in small talk,
inquiring.
◦ The clinician asks the family to describe the
problem that has prompted the clinical contact.
◦ The initial inquiry may be directed to the father,
in recognition of the often tenuous motivation of
many fathers to attend the therapeutic setting, or
to the mother, as the person who may be most
knowledgeable about the family life and
problems.
◦ The therapist should then inquire about the views
of different family members on problematic areas
in the family.
◦ The therapist should observe carefully the
family’s relatively unconstrained nonverbal
behavior.
◦ The exploration of family structure through
observation of family interactions provides the
clinician with valuable clues, including the level of
differentiation, boundary formation, and
boundary flexibility of different family
subsystems and family members.
◦ The clinician is particularly interested in the
functional adequacy of different family
subsystems. The common family subsystems
include the:
 marital – parental
 parent – child; and
 siblings subsystems
 Grandparental involvement, very common in certain
ethnic and socioeconomic groups, would provide
additional subsystems of grandparent – parent and
grandparent – grandchild.
 For the initial session, all members of the
household and significant others should be
invited; these include young children,
toddlers, and infants, who are an important
source of diagnostic data about the family.
 Simple statements such as “I’d like to meet you
all, include the little ones” can readily
communicate the clinician’s goal.
 The clinician should avoid any lengthy phone
discussion to justify the participation of all family
members because a prolonged explanation based
on general assumptions may make the therapist
appear as if he or she lacks confidence.
 The diagnostics interview preferably should be
scheduled for 90 minutes to allow a systematic
evaluation of the family in an unhurried fashion.
 The assessment of family structure should include
the determination of the characteristics
constellations of family conflicts, patterns of
control, clarity of parental authority and
generational boundaries, expression of feelings,
and family rigidity, including the brittleness of
family defenses.
 The assessment of family functioning should
include the exploration of instrumental – adaptive
functions of the family, geared toward enhanced
adaptation and problem resolution, as well as their
expressive – integrative function, addressing the
expression of affect and provision of comfort.
 The diagnostic family interview can be extended
into interviews with family subgroups, such as
parents or children, or with one child for
exploration of other important information that
may not be readily shared in a conjoint session.
 Establish structure in the interview to counter
the common tendency of dysfunctional families
toward chaos, a high level of blame, and
silencing of the members.
 Maintain objectivity, avoid side taking or
premature closure of topics, and elicit the views
of all family members.
 Address the transactional patterns that are
clearly burdensome to many family members
and therefore more amenable to change
(Gordon and Davidson 1981).
 Understand role of different family members
within the family unit.
 Uncover the explicit and implicit rules that
govern family interaction.
 Determine the family’s problem – solving
behavior.
 Understand the nature of boundaries, splits,
alliances, and coalition formations in the family.
 Assess the level of concordance between the
developmental and chronological stages of the
family.
 Assess the concordance between the value
system of the family and the surrounding
community.
 Help the families transcend the repetitive,
immediate, and trivial problems and recognize
the underlying patterns and main issues.
 A significant goal of the family diagnostic
interview is to help the family recognize and
acknowledge its strengths as a family and the
assets of family members, particularly the
index patient.
 When the diagnostic family interview is part
of an overall comprehensive evaluation, it is
best to delay the therapeutic
recommendation until the closing conference.
 Under other circumstances, the family
diagnostic interview should be closed by
highlighting the points of convergence
among the problems of the index patient, the
information gathered from the different
family members, the transactional patterns in
the family system, and the referral
information.
 An experienced family therapist attempts to
highlight the family’s assets, knowing well
that the family is aware of its conflictual
interactions and relationships but barely
cognizant of those assets that are the key to
therapeutic success.
 An inexperienced family therapist tends to
focus on family problems to reveal his or her
observational acumen; this may inadvertently
make the family feel severely disturbed and
discouraged.
 Significant experiences in the past may
influence family orientation and mythology
and directly or indirectly relate to the family
problems.
 Such information includes the early death or
suicide of a grandparent when a parent was
very young, significant financial losses, or
other events that were traumatic for the
family.
 The gradual unfolding of historical
information in the family session is an
important aspect of the family interview and
generally reveals the affectively charged and
dynamically significant past experiences of
the family.
The contracting phase is an important step
prior to initiating formal family therapy.
 It refers to agreed – on issues and goals for

treatment between the therapist and the

family.
 Later on, the goals can be expanded to
include the disagreement between the
parents, such as in their views on child
rearing or on other issues.
 Many treatment failures are due to

inadequate contracting between the family

and the therapist.
 The problems of contracting include covert
disagreement between the therapist and the
family, within the family, or between the
family and referral sources (e.g., the
Department of Human Services or the court
system).
 What to look for?
 Projective identification
 Unresolved grief
 Clarity of ego boundaries and capacity for
intimacy/separateness
 What to think about?
 Internal processes within individual family
members shape family interactions.
 Family member’s motivations, conflicts,
defenses and relationships from the past,
currently influence present relationships.
 Gaining change occurs through family members
gaining conscious insight into previously
unconscious processes generating problems in
family relationships.
 What to do?
 Opening emotional expression in the family
relationships.
 Clarifying communications.
 Encouraging family members to speak from the
“I” position.
 Interpretation of unconscious conflicts to
resolve projective processes, cutoff
relationships, and difficulties in modulating
closeness and distance in the family
relationships.
 Psychodynamic techniques, such as doubling
and role reversal.
 Therapeutic rituals to facilitate developmental
transitions and grief over losses.
 Family genograms.
 What to look for?
 Contrasting the particular family structure with
that “normal” to the culture and developmental
stage in terms of:
 Organization (structure)
 Rules (sequences of action)
 Roles that shape the family members’ actions
 Boundaries
 Hierarchy of power
 Alliances
 Coalitions
 Verbal and nonverbal behavioral sequences
 What to think about?
◦ Presenting problem results from a family
structure out of alignment with the culture
and the developmental stage of the family.
 What to do?
 Actively shift the family structure
 IN session enactments
 Out – of – session homework assignments
 What to look for?
 Here – and – now context of the problem
 Who, what, when, where, and how people are
involved in trying to solve the problem
 What to think about?
 “The solution becomes the problem”
 Difficult life – cycle transitions give birth to
clinical problems when people persist in old
coping strategies but relational and
communication processes need to change to
meet new life contexts.
 What to do?
 Psychoeducation
 Direct behavioral assignments to adopt new
problem – solving strategies
 Defiance – based, paradoxical interventions
 What to look for?
 Family member difficulties in recognizing
deviant behavior
 Lack of clearly – defined family rules
 Problems in emotional communication among
family members, usually a paucity of expression
of positive feelings coupled with an excess of
negative expressions
 Relational conflict due to a paucity of relational
skills
 Relational conflict due to interpretive errors
based on family assumptions or cognitive
distortions
 What to think about?
 Each member of the family is assumed to be
doing his or her best to cope with the
behavioral contingencies perceived at that point
in time, given the practical and emotional
restraints experienced.
 Family members need to learn cognitive and
behavioral principles of learning.
 Family members need to gain skills needed:
 To reinforce desired behaviors;
 To eliminate reinforcement of undesired behaviors;
 To modify faulty assumptions and interpretations
about other family member’s actions;
 To learn skills for communicating clearly and
effectively.
 What to do?
 Conduct psychoeducation about the presenting
problem.
 Conduct skill training in empathic listening
expressing positive feelings and speaking
negative communications respectfully.
 Conduct training in a problem – solving and
conflict – resolution skills.
 Teach operant conditioning strategies for
behavior shaping with children.
 Teach principles for contingency contracting to
replace coercive and blaming behaviors with
contracts specifying what each family member
agrees to perform.
 Teach family members to utilize behavioral
observation and thought diaries in out – of
session assignments to track patterns of
thoughts, feelings and behaviors that generate
symptoms.
 What to look for?
 Listen for exact usage of language expresses as
metaphors, stories and beliefs.
 Listen for first – person narratives from the
family members’ lived – experiences that imbue
with meaning such abstractions as “love”, “trust”
and other important language of relationships.
 
 Note exceptions, or unique outcomes, when
problems might have occurred but surprisingly
did not.
 Note what is happening at times when problems
are absent.
 What to think of?
 The limits of a person’s language constitute the
limits of his or her experiential world.
 Narratives, or stories, are the basic units of
human experience.
 A canon of personal narratives shapes the
meaning each family attributes to his or her
experience.
 Narratives of identity, about which one is as a
family member, strongly influence family
interactions.
 Family conflicts emerge: 
 When lack of narrative skills makes their experiences
unintelligible to others;
 When the available narratives preclude ways of relating
other than conflictual ones;
 When specific words or expressions hold very different
meanings for different family members due to the
personal narratives with which they are associated;
 When family members become positioned relationally
such that they cannot hear, tell, and/or expand their
stories in conversation.
 What to do?
 Focus on creating a dialogue in which important
personal narratives can be safely expressed,
heard, and reflected upon by family members.
 Ask questions that elicit forgotten, or
unnoticed, narratives of family life that open
better possibilities for solving problems that the
current narratives that have dominated the
family dialogue.
 Engage family members in an inquiry of:
 What is happening in family interactions when
problems are being solved successfully and symptoms
are not occurring?
 Skills, practical knowledge, competencies and
resources of the family that can be brought to bear
upon the problem.
 Family Demographics & History

Family Therapy Process

Intake Interview

Case Conceptualization &

Treatment planning

Session 1 Session 2 - 5 Session 6

Building Working Rebuilding Termination

Alliances family
connectedness
Combining
strategic FPT with
art Use of art
tasks
Free drawing task

Family mural art

task