“The family is the unit of concern, the unit of observation, and the unit of healing.” (Combrick-Graham, 2014)

What helps us survive this complicated life? Systems. As humans, we thrive when part of a network of support, inclusion, and collaboration. And family is the ultimate system, making family therapy an invaluable addition to any program. Right?

Yet, when we therapists talk about working with families in therapy, our collective anxieties rise. As much as we may talk the talk, we don’t walk the walk. The truth is, families are not seen very often in therapy. Even less frequently do we bring the whole family into the room.

So what feeds this anxiety? Why is it that, despite our understanding of its importance, we are so reluctant to include families? What are the preconceptions, misconceptions, and fears that interfere with therapists doing the work?

I posit that there are several reasons we’ve shied away from this type of work. It’s not that we think any less systemically, or see the value in families any less. I believe there are a few different versions of family therapy avoidance.

The Context of Family Therapy

Modern society feels far busier, more stretched, and more burdened than ever before; something we are more and more attuned to accommodating in therapy. Having the whole family participate in treatment was somehow more feasible when members of the family weren’t operating in silos. Yet the argument can be made that getting the whole family to commit and participate in family therapy is an intervention, as it takes considerable work to bring a whole family together amidst the chaos of life. I’ve had clients reflect on the sense of commitment that is demonstrated when family members take the time to attend sessions. And the reverse is true as well; much disappointment and stagnation come from a family member’s absence in the treatment.

Parenting has changed over time as well. Many families are focused on ‘perfection parenting’ and raising ‘successful kids’. The emphasis on getting it right, both for parents and children, challenges the work of a family therapist who is tasked not with promoting perfection, but with improving relationships and parenting practices. At times, it feels like an impossible balance managing this pressure for perfection with teaching the art of vulnerability. It is all too easy to join the bubble wrapping, the snowplowing, and the avoidance of sitting in the messiness of it all.

So we do what we can control; we shy away from family work and try and help through the individual. But of course, this has limited benefits. When a person leaves their therapist/doctor’s office, they are still active members of a family, part of a system. By attempting to help through the individual, we put blinders on to that part of their lives, thinking that we can work in isolation from it.

Parent coaching is another way we end up fragmenting the family work. This work is always easier without the child in question in the room. Advice giving is simpler. We can help the caregiver explore and examine what changes they can make to the family as a whole. I have found great success in providing parent coaching; however, what I’ve notices is lost in this modality is the impact of modeling reflection by isolating coaching from the child. What worries me is the unintended consequence this has on the training of future therapists. As we do more parent-coaching, more systems-based individual work, we end up with few opportunities for novice therapists to learn what it feels like to work with a whole family. We do a disservice to the next generation of therapists who we inadvertently train to be averse to family work.

So how do we get back to the business of family therapy?

In vivo experience, observation (formal and informal), supervision, enactment, and curiosity are all ways we can choose to engage in family therapy. Family is transformed by seeing its interactions in real–time, through the eyes of a curious and supportive observer. The observer/clinician gives the family an experience they cannot see when they are too close to the fray – how their internal thoughts and feelings give way to interactions that strengthen or weaken the essential bonds we hold throughout our lifetime. The social connectedness of humanity is what binds us, and can also damage us. It is the skill of and process of the family therapist that can bring this into the light. Family therapy is cost-efficient and often more time-efficient than individual therapy. It helps more people more quickly and can promote significant change.

Family Therapy as Self-of-the-therapist Work

Family therapy goes beyond imagining or deciphering someone’s internal state of mind (Combrick-Graham, 2014). Perhaps this is what makes it so challenging. Instead of observing the parts of someone’s life that happen outside the therapy room, we look for it inside the room in order to enact it. However, this type of practice is often avoided, especially if we are conflict-averse in our own lives (as many ‘diplomatic’ therapists tend to be). We often struggle to face our own vulnerabilities. There is a distinct unease therapists face when we are thrust into roles in session that resemble our family of origin. The negotiator, the communicator, the peacemaker, the cleaner are all roles we practice in our own lives, and at times are pushed into occupying as the family therapist. Our ability to manage this difficult position depends on our awareness, adequate supervision and training, and the willingness to be vulnerable and understand our internal experiences as the therapist with our own histories.

In their article on family therapy, Bruenlin and Jacobsen (2014) identify the family therapist as a family’s “general practitioner:” one who is trained to see and explore all aspects of someone’s condition, and in this case, the family. To me, this serves as a brilliant comparison. A general practitioner must see the whole picture to be effective; must be an experienced diagnostician, able to understand a multitude of maladies that could be influencing one’s health and wellbeing. This practitioner must be brave and courageous to explore and support all parts of the family.

To encourage more family-centered care, therapy, and systems thinking, we need to promote the idea of working with families at all levels. This means training not only potential psychotherapists but other mental health professionals, psychiatry residents, etc. to conceptualize family work from the very first moment of training. If we face our preconceptions, misconceptions, and fears head-on, we will be much more willing to take the risk of engaging with families. Systems that train the next generation of therapists in the importance of working with families will not question whether it is an important component of care but simply when and how to get started.

References

Bruenlin, D., & Jacobsen, E. (2014). Putting the “Family” Back into Family Therapy. Family Process, 53, 462-475.

Combrick-Graham, L. (2014). Being a Family Systems Thinker: A Psychiatrist's Personal Odyssey. Family Process, 53, 476-488.

Gehart, D. (2018). The Legacy of Tom Andersen: The Ethics of Reflecting Processes. Journal of Marital and Family Therapy, 44(3): 386-392.