Family systems therapy

Although I’ve never been a parent, during my thirty-plus years as a psychotherapist I taught parenting skills to many people in individual, family and group therapy, as well as community consultation and education activities. Even stable, functional parents might sometimes need coaching to improve their parenting skills, while some dysfunctional parents might not even grasp the concept, because they unquestioningly raise their children the way they were raised. The most dysfunctional parents can’t distinguish their child’s needs from their own. They rationalize abusive behavior, telling the child that they did it “for your own good” or “because you deserved it.” No child deserves to be abused, but many people have been taught by their families to blame themselves for abuse they suffered in childhood.

Family systems theory provides a helpful framework for doing family therapy, because the focus isn’t on simply achieving symptom remission in the child whose “problem behavior” is what brought the family into therapy. (“She throws temper tantrums.” “He can’t stop wetting the bed.”) Instead, the focus is on the family dynamics that perpetuate the symptom or problem behavior. The therapist avoids labeling Johnny as the identified patient when she says to the family, “This isn’t just Johnny’s problem, it’s a family problem.” If the therapist can facilitate specific changes in the dynamics of the family system, the problem behavior or symptom resolves itself. Dysfunctional families can learn to be more functional. I’ll give three examples: temper tantrums, bedwetting, and compulsive masturbation.

Tom and Linda have brought their daughter Sue in for family counseling because she throws temper tantrums.  She’s the identified patient in the parents’ minds, but her behavior doesn’t exist in a vacuum. Tom and Linda say that they’ve tried everything, but the tantrums have just gotten worse. I explain that it’s normal for children to test the limits and try out new behaviors, to see what they can get away with. The first step in this family system interventions is to figure out the goal of Sue’s behavior – usually power or attention. If it’s power, Sue has learned from experience that she can wear one or both parents down, and they end up giving her something she wants (ice cream, a toy, staying up past her bedtime) in order to get her to stop. If her goal is attention, she’s learned from experience that one or both of her parents will hover over her and give their full attention to her, afraid to leave her alone when she’s having a tantrum.

In such cases I’d explain the behavioral psychology term positive reinforcement: rewarding any behavior, whether it’s seen as positive or negative,  tends to cause an increase in the frequency of its occurrence. Negative reinforcement isn’t  punishment, but rather the withholding of positive reinforcement. So if the child’s goal is power,  never give into her demands, in order to get her to stop screaming. (Both parents have to be consistent in their use of systematic reinforcement.) If it’s attention, both parents need to ignore her when she’s in tantrum mode, and give her positive attention when she’s behaving. Ignoring a tantrum can be very hard for parents at first, but when their response changes in a consistent manner, the tantrums stop.

I’ve already written about my “one-session enuresis cure,” and my family system intervention that enabled instant success in helping a ten-year-old boy to “keep a dry bed” after weeks or months of bedwetting. The mother came in with her miserable, humiliated son. She and her husband had “tried everything,” but the bedwetting was now a nightly occurrence. I explained that the cause of the enuresis was anxiety (“nerves”), and that anything family members did to increase his anxiety would just make the problem persist. I was told that the father yelled at him and spanked him when he wet his bed, and his siblings ridiculed him. We came up with a plan to change the family system response to Junior’s problem: No threats, shaming or corporal punishment. No yelling at him, or taunts from his siblings, etc. There was more to my one-session family intervention (involving the use of strategic metaphor and storytelling), but the mother was evidently successful in implementing our plan. When the family system response changed in a specified way, the symptom immediately went away.

A classic family systems technique called prescribing the symptom can be illustrated by the case history of a twelve-year-old “identified patient” (Ron), brought in by his red-faced parents (Tina and George), because they couldn’t stop him from compulsively masturbating. George and Tina were conservatively religious. They’d tried everything from prayer to punishment to pastoral counseling, and nothing had worked. At first it just seemed like Ron was always playing with himself whenever he thought he was alone. His parents had taught him that it was sinful, but he said that he just couldn’t help himself. Lately he seemed to be less cautious about when and where he masturbated, and his parents felt helpless.

Being family systems-savvy, the therapist knew that Ron’s “compulsion” was a symptom brought about by his parents’ response, and that Ron could control his autoerotic behavior if he felt motivated to do so. Paradoxically, by claiming to be powerless over his own behavior, Ron had power over his clueless, humiliated parents. The cure was to prescribe the symptom, and change the power dynamic within the family. So the therapist might need to convince the parents that private masturbation was something they could accept and not over-react to, as long as the behavior was no longer compulsive and indiscreet.

Once Ron heard his parents agree, in session, that he wouldn’t be criticized or punished for engaging in a normal sexual behavior – as long as it was done in private – the therapist might say something like this: “Now, what I say to Ron next might surprise you two but, believe me, this will work. Ron, paradoxically, your problem is that at this stage of hormonal development, you’re not masturbating enough! You say you average maybe four times a day? I think you need to do it at least five or six times a day, until you eventually reach the point where you feel like you have control again.”

By prescribing the symptom, the therapist has temporarily entered the family system and has taken the power out of (ahem) Ron’s hands. In effect, he has said to George and Tina that Ron is no longer responsible for/in control of his sexual excesses, he is. This defeats Ron’s tactic of being out-of-control and frustrating all attempts by his parents to establish control over this behavior. This change in the power dynamic – in behavioral terms – extinguishes the undesirable behavior. Ron no longer has a motivation to act like his behavior is out-of-control, because his parents are no longer freaking-out. A successful family systems-oriented therapist can accurately assess family dynamics and craft effective interventions that help make families more functional and harmonious.