Family Therapy (Intermediate)

Social Service Institute

16 September 2020, 9am to 5pm

Family therapy is always about systemic change – in the structure and process of the family
- Structure (Minuchin): how is it not helping, how is it maintaining the problem
e.g. no one at home to monitor the accountability of the child, power
family structure: boundaries, alignment, power, hierarchy
- Process (Bowen): There must have been a start in helping the pattern
process in interaction in terms of setting of rules, clarifying of roles, open
communication
o Equifinality, circular causality, feedback, homeostasis
 which parts needs to be fixed?

Focus: Minuchin’s Structural Family Therapy Model and Bowen’s Transgenerational Model
- Ideas and assessment

BOWEN (generates awareness through reflection and psycho-education)

Ideas
Fusion and differentiation
Undifferentiated family ego
mass
Triangles
Multigenerational
transmission process
Nuclear family emotional
system (triangulation,
distancing self, dysfunctional
or overly submissive)
MINUCHIN (actively manipulates existing structures and patterns of interaction)
Ideas
Family Structure
Boundaries – flexible,
permeable, rigid, closed OR
boundaries between
subsystems
Alignment (coalitions)
Power - dynamics
Assessment Methodology/Intervention
Differentiation of self Genograms
- Enmeshment in Therapist in the “detached-
family and worker involved” position
relationships Personal time and
- High emotional messages
reactivity ‘I’ position
Tracking of FOO & historical “tempest in a teapot” and
patterns (pathologies) humor
Assessment Methodology/Techniques
3 generational genogram Creation of transaction
Identifying existing Joining with the
structures and dysfunctional transaction
patterns Restructuring
- Transgenerationally
- Rigid triangle Role of therapist: producer,
- Alliances and cutoffs director, protagonist,
narrator
 leading, directive, trying
to introduce certain
concepts

Home visits – what to look out for

- Home environment
- Patterns of communication and interaction: closeness, who sets the tone and
agenda, who starts first
 - Family portraits, artwork, pictures, who stands next to who, who is absent in family
photos

Morpho-stasis: Forces for change

Object relations

Bowen’s ideas

Genogram: see the patterns of the emotional process that operates in the family. The
clients also begin to see the connections of the reactions of individuals to life events and
how that impacts the entire family. A good history enables one to get beyond blame and
appreciate the efforts that the family members are making to survive the anxiety of the
moment.

Differentiation is the ability to take a more neutral position, separate thoughts from
feelings.
- The higher differentiation, if a person says something to you, you are able to hold
that thought as a cognition and not allow it to turn into a feeling.
- The lower differentiation, the greater likelihood that the person will be unable to
differentiate himself from other family members = fusion
- When an entire family is fused, it is called undifferentiated family ego mass
(emotional stuck togetherness of families that have inadequate interpersonal
boundaries
- “Differentiation of self is defined as the degree to which one is able to balance (a)
emotional and intellectual functioning and (b) intimacy and autonomy in
relationships…On an intrapsychic level, differentiation refers to the ability to
distinguish thoughts from feelings and to choose between being guided by one’s
intellect or one’s emotions” (Bowen, 1976, 1978)
- A metaphor of differentiation that is helpful is that of a raging river. Imagine a loved
one who is caught in the raging rapids. Maybe they are in the throngs of addiction,
maybe just incredibly depressed or lonely, but regardless they are drowning. Of
course our first instinct is to jump in and rescue them, thinking that is what love
looks like. But if you jump into the raging river, you too will surely be sucked into the
torrent and swept away by the rapids. That is not love, but suicide. True love and
proper differentiation is to stand on solid ground, with feet firmly planted on the
water’s edge, with your arm reaching out towards your loved one, allowing them to
swim towards your hand, when they are ready to receive the help they long to
attain.

Emotional reactivity: when people don’t respond, they react

- The lower the level of a person’s self-differentiation, the greater their likelihood to
be emotionally reactive

Emotional triangle: they develop their own rules, the more one person tries to change the
other two, or one person with his/her habit, the more that person reinforces the
relationship
- 2 family members recruit a 3rd to siphon off their anxiety into
 - When a rupture happens we tend to immediately turn inward towards self-contempt
or outward to blame, to shared contempt (other-centered contempt) as an effort to
get the dysfunction outside of ourselves as quickly as possible. Neither of these
options are helpful solutions to the core issue of emotional enmeshment/
triangulation, thus the need for discovering how to attain healthy differentiation.
- Common: parent child parent = “It is a simple equation: to the extent there is a loss
of intimacy, passion and purpose with one’s spouse the higher the probability a child
will be used as a spousal replacement.”
- We find ourselves lured into these triangulated relationships because we have a holy
desire to be included, affirmed, and loved. At first these relationships give life and
promise of hope fulfilled, but over time the emotional drainage serves to only take
our very life away.

Nuclear family emotional system: family’s coping mechanism, means to deal with tension
and stability  some are dysfunctional
- Families seek help when dysfunction surfaced in one or more of the 3 main stress
areas of the nuclear family system (e.g. marital conflict, dysfunction in spouse,
dysfunction in child)

Family projective process: chronic triangulation on the most vulnerable child

(youngest/weakest/oldest)  this process creates a lower level of differentiation in the
targeted child

Emotional cutoff: pseudo-differentiation (a person may appear to be differentiated but

actually has many unresolved issues and difficulties separating thoughts and feelings)

Multigenerational transmission process: family dysfunction is passed on generationally, an

individual with certain level of differentiation seeks out a spouse with a similar level of
differentiation
- Lower level of differentiation are therefore created by the multigenerational
transmission process

Societal regression: same principles that apply to the emotional system in the family can
also be applied to the society at large

Common issues seen in EIPIC situation:

- Disciplining/parenting
- High expectations
- Caregiver stress: depression, anxiety of mother
- Imbalance of roles between parents
- Lack of either parent’s involvement, can be manifested in overinvolvement in child
to establish a sense of purpose in the parent child relationship
- Denial of child’s condition or lack of knowledge
In an EIPIC situation, what would be the opportunities that would require family
therapy?
- When grandparents are also involved in the disciplining of the child
- When family issues stem from FOO, unhealthy communication and interaction
 patterns, beliefs of roles of parents
- Issues related to family life cycle
- Triangulation or parentification
Concerns/Challenges?
Complex family makeup e.g. helper is the one holding the family together, or
grandparents like they are already doing so much by helping to take care, don’t want to
involve them
Engaging family members with the limitations of opening hours
Unwillingness and lack of rapport, take maybe 1 yr to build rapport for them to be
comfortable enough to share
- Unwillingness of fathers: male ego = self reliance and self efficacy,
- we are interested in enabling u to be a better parent, a more supportive partner
and we realize that some men don’t have the tools, so we are here to give you the
tools (psychoeducational approach = use what u think is useful, throw out what
you think is not useful, you decide)
- working manners and methodology is different
- Start with the willing one: equifinality: there are multiple ways to same
destination
Parents want to fix their children but not themselves
- How not to disempower parents: affirm that they’ve been trying their best
Expiry date or Not long term work: end when children graduate or CP work is short term
- Boundary spanning: key concept to case management, we have come to the limit
of the boundary and we cannot go beyond that
- Connecting and referring to another agency who is able to do more long term
work

Control oriented or change oriented intervention

- Control: what you are doing is wrong, not fitting the norm, you need to conform to
the environment  Singapore context is often is type of intervention, use power to
pressure
- Change: what you are doing indicated that there is something not right in the
environment so the environment need to change so that your life is more well
ordered  changing methodology in order to get clients to change, equifinality

Pre-session consideration:
- Structure: e.g. hmm it’s not right that child is deciding everything, or things changed
when the grandparents moved in
- Functioning: how they interact is at odds
- Critical needs take precedence sometimes
- Work systemically with parents: family is suffering because the couple relationship is
bad, don’t fix the whole family but marriage is the one that needs more attention,
it’s how you look at and approach the situation
- How the intervention is framed: when inviting another member to the session

During the session:

- If 4 people are coming, prepare 6 chairs, 4 chairs for the family members, 1 for
yourself and 1 extra: let family sit themselves  following minuchin’s idea of spatial
 positioning: who sits with who (people you like, people you don’t like, people you
feel safe with)
- If can, sit next to the bad boy or ostracized person, or the problem person, want him
not to feel intimidated or isolated
- UNLESS: family violence, chop the seat nearest to the door or with the alarm, to
have control of the exit and entry, you can let other people out, not that you run out
first
- Order of engagement: who to speak first, who next, who next. Usually the one you
speak to first is the most enthusiastic or the one with the most power. If you have to
guess, follow cultural rules and beliefs e.g. males hold the most power, unless
mother is the one who called for the meeting
-  want to align self with the family as soon as possible. Don’t see counsellor as a
threat to the order
-  so that everybody gets a turn, and come prepared when it’s time for them to
share. Doesn’t mean everybody must speak in the same way

Case study #1

Presenting issues:
- Inappropriate parenting and neglect: no intention of harm, but fixated beliefs. No
preschool, no early intervention, sleep in morning and awake at night and whole
family has to be the same
- Denial of children’s diagnosis
- Mother is on LTVP, 3rd child is stateless
- Mother disagrees with the things father does, but she has no options and sees him
as a savior
- FOO possible mental health issues (father’s side)

1) Control oriented change is not helping the family; if father is convicted, then
family will need to move back to China
2) Affirming the parents that we see that they care for the family and they want the
best for the family, and are trying what they can for them

Father:
- Rolling with resistance
- Understand the function of father’s resistance: Fulfilment of roles (positive
connotation of function) understanding function helps us understand pattern
-  Don’t take away his role and purpose from him
Mother:
- Continue to empower the mother e.g. to work

Case study #2
Presenting problem:
- Behavioural issues and throws tantrums 6yo

How are the parents enabling child’s issues?

 How does the parenting style reinforce certain behaviors or thinking?

be mindful of intensity: it’s an art, try not to leave the man in the grill for too long and ask
him difficult questions. He may burn if left for too long
If the family is intending to change but all is relying on one person to make change, it wont
happen
Ensure that what you’re pushing for can be supported by the system; don’t intervene too
quickly as it may trigger more conflict. Start with something simpler like do a task together

Family Therapy (Intermediate)

Social Service Institute
17 September 2020, 9am to 5pm

Case study #1
Family background:
60yo widow (4 months ago), 41 and 38 yo adult children
41yo single working and living together, 38yo marriage on the verge of divorce
Wife is Taiwanese with a 6yo daughter

Presenting issue:
60yo depression, many regrets, didn’t do enough for children to build with deceased
father

Application:
Enmeshed relationship with mother: when he’s down, mother is also down and affected
by his low mood

Systemic hypothesis:
**must connect with the presenting problem: what is the reason for the presenting
problem
** what is the person trying to tell through the symptoms?
** how is the family maintaining those symptoms?
- Mother’s depression is function of loss of purpose in role, which is why FT seems
reasonable
- Mother’s depression is affecting her relationship and functioning at home with her
children
- Given the recent losses in the family, mother may feel a bit lost in terms of her
identity and direction = to see how family can re-orientate itself given the recent
changes in the family
- Function of her depression is to sound to the family that we need to regroup
ourselves as she sees the connection in the family is not what it should be
- The loss of father has triggered an urgency in client to strengthen relationships =
need to hold on to each other during difficult times
- The loss of father has hastened mother’s concern that there’s a need to
strengthen family relationships in view of the son going through this difficulty
himself, idw my son to realize the importance of r/s too late

Intervention:
Hayley: Families usually come in with a crisis = you must find out what is the crisis
Old way of coping is no longer applicable, family is shaken up and haven’t learned new
way of carrying on
 what is the nodal event? Son’s marriage? Father’s passing?

- Redefine closeness, what it means to different people

- It’s a reasonable objective to want a family session to highlight mother’s issues to
the family
- Small tweaks to better support mother, rather than change in process of system

How to ensure that family and children’s needs are addressed as well? In this case it was
mostly of what children can do to meet mum’s needs but how can mother do to support
their needs as well?
 how did that unmet needs happen? Breakdown of communication of own’s needs?
Then can the goal be for everyone to work on how they can communicate their own
needs?
 Sense of we-ness is lacking and weak, so that’s why their participation is forced and
slightly unwilling
- Reflect and check in: working on mother’s needs doesn’t seem to be top priority
for you, it’s different from your view of what needs to be done
- CHANGE IN PRESENTING ISSUE/HYPOTHESIS: What am I hearing is that
depression is just the smoke, but the actual fire is the upheaval to Taiwan,
resulting in a loss for everyone
- Rather than recreating something that was lost, make new memories
 - (Shifting in paradigm) Changing ideas of what is support: to accept that sometimes
when she closes the door, she needs her own space and sometimes we have to be
the brave ones to take initiative

Case study #2
Family background:
- On the verge of divorce as requested by mother as she doesn’t want to burden the
family, mother has depression, cancer and history of self harm: fsc has no access
to her
- Mother didn’t tell anyone about her cancer until after a surgery when the hospital
called the family
- Father is okay to proceed as he doesn’t want to trigger her
- 4 children, 13 yo has ADHD, dyslexia and behavioural issues in schools, but shows
no issues at home and in church
- Harsh discipline on 13yo by mum

Presenting problem:
- Child’s behavioural issues

Systemic hypothesis:
**must connect with the presenting problem: what is the reason for the presenting
problem
** what is the person trying to tell through the symptoms?
** how is the family maintaining those symptoms?
** is it mere coincidence or is there something going on? It might be a small information
overlooked?
- 13 yo is acting out in school to get attention
- A lot of detachment in the home
- Fusion in a sense that everyone is reacting to mother

Link between child’s behavioural issues and mother’s depression?

Attempt to get mother’s attention because he is scared for her health that she will be
gone soon?
 They deal with information is by hiding: family rule is to hide, put more elephants in a
room, family tradition
School environment requires compliance, which is a different situation compared to at
home, different expectations which is maybe why it’s more difficult for him to do in
school
Not causal relationship but exacerbates his coping

Intervention: what do you need to find out to test is hypothesis is true?

- Teach him skills on how to manage his emotions

**You can work individually, promoting system’s change and disrupting processes and
structures, don’t need to talk to ALL the family members., the ripple effect of systems
thinking and equifinality principle. He’s the most ready to disrupt the family rules, plant
ideas here and there, create family havoc by asking questions
 Case study #3
Family background:
- Parents are separated, father physically abused 14 yo son. Father was incarcerated
due to the abuse and other white collar crimes
- In the system since 9yo, history of domestic violence
- Separated but not divorced, they got a house together, dad provides financially
and doesn’t want to take care of child, mum doesn’t plan on getting back together
with dad
- Mother is an alcoholic, possible mental health issues as she has a negative
perception of professionals
- Son has behavioural issues, enmeshment with mother and pattern of son doing
the right things so that mother is not angry
- Mother is permissive, more of a friend relationship with son but she wants child
back, her life revolves around child
- 6 miscarriages before this child, really wanted this child.

Presenting problem:
- Mother wants son to solve his behavioural issues before returning to home
- Mother refuses to work with professionals to work on parenting and alcoholism
- Son is showing behavioural issues

Systemic hypothesis:
- Mother is unwilling to work with professionals because there is no carrot or
motivation for her to change, and either way son will still go back to her
- Mother does not feel like her way of parenting a problem because of the pattern
of communication where son always tries to not make mum angry by doing the
right thing and FOO influence, she’s resilient enough to come out of it with no
harm
- FOO: how mum was brought up led her to believe that it was solely child’s fault
for not being able to behave
- Understand the function of mother’s resistance and mother/son enmeshed
relationship: Triangulation = Fulfilment of roles (positive connotation of function)
understanding function helps us understand pattern
- Mother is resistant and son is manipulative answers because both share the same
goal of reunification
- Son had a negative experience with systems, changes their pattern in thinking

Intervention:
- Teaching boy how to regulate his emotions better
- [Involuntary and unwilling clients = set bar very low] Removing that obstacle of
difficulties in communication (ourselves as authority), admit that there’s nothing
much that we can do. Removing that authority from ourselves,
o e.g. no matter what u say to me, it wont matter to your being discharged,
nothing will jeopardize your reunification
o It is only a matter of time before your son is reunited with you, your
objective of reunification will be achieved. What is at stake is during this
 time, when you will be reunified, there is a range of services that’s
available that could make the reunification a better and more workable
one, this is what we’re trying to provide
o eg with men who are hostile, my job is to do my best to keep you out of
jail, not to reform you, not to make u a better man, if you want can, good.
But 1st priority is to keep u out of jail. Usually when they hear this, they feel
better bcos they also don’t want to go jail
o how we can work with the systems to that clients can be more authentic
with us

[Refer to Object relations.pdf]

Function of the pattern, where the patterns hopes to do, patterns impact and effect on the
family

Self-disclosure about countertransference: to recognize what’s going on in the family and

acknowledge the things that they are going through

[Refer to word doc]

e. Permeability of boundary, they’re not getting in right = design intervention that will help
them create the boundary
e.g. at this point I would like the children to leave the room, because there’s something I
want to say to your parents. You may be asked some questions after this by the children,
but I would like you to tell them that nvm it’s between mum and dad, don’t feel like you
need to share anything
 telling them it’s ok not to tell to create that boundary
 Start the conversation on what are topics to be discussed openly, and behind closed
doors

Manipulation of space: in an empty training room, ask family members to use chairs to
represent emotional connection or distance and place them in the training room. Take turns
to show each person’s spatial representations.

Termination phase:

Sometimes the problem is not solved, but family can manage it and they know what to do
Although things have improved, what have they learnt in the process? Was there a change
in my thinking?
Is this a complete relapse? Or is this a period of adjustment, sometimes they have it right,
sometimes they struggle? Change is not gonna happen immediately.
Agency: Family’s ability and confidence  what have done to be where they are today,
what is it that they have learnt
Rituals: things we do to celebrate something
Discuss and dissolve: Talk about goodbyes, the fact that we have to come to a termination

External readings

How to be more differentiated?

We must be gentle and kind to why we got into the relationship in the first place. Second we
must have the courage to name and address what needs to be changed within our own
heart, and not focus on what we hope to change in the other people involved. Why were
you drawn into this type of relationship? What core needs are you attempting to meet by
being triangulated or promoting a triangulated dynamic? What does the quality of the
relationship say about you?

And finally we must reclaim a strong sense of self. Do you know who you are separate from
the blessing or curse of another? Do you know your place in God’s Kingdom? We must have
a deeply anchored sense of who we are, rooted in who God has called us to be. If not, we
can be seduced away by well intentioned folks who unconsciously wish to divert us so they
can get their own emotional needs met.

Being well differentiated does not mean being emotionally closed off or cold hearted, but
quite the opposite. It means being so in touch with how you feel and why you feel it, that
you make the difficult choice of doing what is best for you. This is not a selfish act; knowing
which emotions are yours to bear and which are not is a sign of emotional maturity and
growth.

The Four Steps of Differentiation

There are four key steps to psychological differentiation. The first steps involve becoming
aware of the various ways we have been influenced by destructive individuals and
experiences from our past. The next steps involve taking actions to break with these old
identities in order to ultimately become our truest selves. As Dr. Firestone points out,
“Becoming a differentiated person is a lifelong project.” So be patient and compassion
toward yourself as you move through these steps.

Step 1:

The first step of psychological differentiation involves breaking with destructive thoughts
and attitudes toward ourselves that we internalized based on painful early life experiences.
We can start by identifying these negative thought processes, which Dr. Firestone calls the
critical inner voice, that are harmful or negative toward the self. Some of these thoughts
may seem positive at first (either self-soothing or self-aggrandizing), while others will seem
hostile, self-hating, paranoid, or suspicious. Once we become aware of these “voices,” we
can develop insight into the sources of these destructive thoughts. We can develop this
insight by thinking about which specific individuals or experiences may have lead us to feel
these negative ways about ourselves. Then we can try to answer back to these skewed
thoughts in our own point of view. By learning to challenge this inner critic, we separate
from the “parent” we’ve internalized, a step that may cause us anxiety but will ultimately
free us to become who we strive to be.

Step 2:

The second step of differentiation involves recognizing and changing negative personality
traits in ourselves that are an incorporation of the negative traits of our parents, caregivers,
or other influential figures. Many individuals are surprised to find that, despite their best
intentions, they often act in the same negative ways a parent did — reenacting the very
actions or personality patterns that they swore they would never repeat themselves.
Altering these unpleasant or toxic personality characteristics — addictions, vanity,
phoniness, self-centeredness, a victimized orientation toward life, attitudes of superiority
and contempt, among others – is a powerful way of saying goodbye to our past. It is
important to be proactive about changing these negative personality traits without being
self-hating or falling back into your critical inner voices. Understand that you came by these
faults honestly and that you have the full power to change them.

Step 3:

The third step of differentiation involves looking into the psychological defenses we
developed as an adaptation to the pain and distress we experienced growing up. To
differentiate from the more childish aspects of our personality, we need to identify and then
give up the patterns of defense we formed to deal with pain early in our lives. We need to
recognize that the defenses we formed to protect ourselves as children often limit us in our
adult lives. For example, if we were intruded on as children, we may feel excessively
guarded as adults. If we were rejected as kids, we may feel distrusting in our relationships.
People tend to cling to these defended ways of responding to others and remain
emotionally trapped in cycles from their past. As adults, it’s important to give up the hope of
ever filling the vast voids we felt as children. In order to become psychologically
differentiated, we need to, in effect, say goodbye to our “child selves” and live fully as the
adults we are now.

Step 4:

The final step of psychological differentiation involves developing our own values, ideals,
and beliefs rather than automatically accepting the beliefs that we grew up with or those of
our culture. We should strive to lead a life of integrity, according to our own ideals, in spite
of social pressures to conform to the standards of others. We should resist influences that
are oppressive or restrictive of individual human rights. It is also important to formulate
transcendent goals, those that go beyond ourselves and our immediate family, and to take
steps toward fulfilling these goals that give personal meaning to our life.