J . Chitd Psychol. Psychiat., Vol. 19, 1978, pp. 57 to 62. Pergamon Press. Printed in Great Britain.
ANNOTATION INDICATIONS AND CONTRA-INDICATIONS FOR THE USE OF FAMILY THERAPY S. WALROND-SKINNER* FAMILY therapy can be defined as the psychotherapeutic treatment of the family system using as its basic medium conjoint interpersonal interviews. It includes many sub-specialities, the most important of which is conjoint marital therapy—which addresses itself to the marital system, in the same way that family therapy focuses on the family system. For the purposes of this annotation, the literature referring to indications for both family and marital therapy will be discussed. A variety of problems confront the theorists who would attempt to define the conditions which indicate or contra-indicate the use of family psychotherapy as the treatment of choice for emotional, psychiatric and behavioural disorders. Not least of these is the immaturity of the subject itself—family therapy having been recognized as a valid psychotherapeutic modality for barely 20 years. Stein (1969) for example, writes of the "experimental, evolutionary and partial quality of most investigations in the family field". Hence it would be true to say that family therapy is still at a "pre-theory" stage of development, with practitioners and researchers simply lacking sufficient experience of their subject to be able to offer anything approaching a definite set of conditions for its use. Empirically based and properly controlled outcome studies into the effectiveness of family therapy are almost entirely lacking (Wells et al., 1972) and whilst work specifically focusing on the outcome of conjoint marital therapy has been rather more widespread (Gurman, 1973; Gurman and Rice, 1975) this too is inconclusive. Lacking too is any established taxonomy of family types which would enable the practitioner to move outside traditional psychiatric nosology into a genuine systems framework of interpersonal disorders (Walrond-Skinner, 1976). The practitioner, working at this pre-theory stage and requiring some guidelines for case selection, develops working metaphors to describe the conditions which appear to him to respond favourably to treatment. Skynner (1976), for example, talks of a "kind of sandwich distribution regarding the suitability for group treatment whereby the most primitive levels of development and the more sophisticated levels could use group situations fruitfully . . . while the level intermediate between these 'top' and 'bottom' levels requires a dyadic relationship". Obviously, such metaphors, arising out of the day-to-day experience of the practitioner, provide fruitful ground for developing hypotheses. The danger arises when apparent confirmation of the metaphor's accuracy occurs subtly over time. It then becomes enshrined not as the product of controlled research, yet inappropriately takes on the status of scientific fact.
•Family Institute, 2 Four Elms Road, Roath, Cardiff CF2 lLE, Wales.
57
58
S. WALROND-SKINNER
A further difficulty needs to be borne in mind. The term family therapy describes a modality, which in turn embraces a complex range of methods, each employing treatment techniques specifically suited to the particular approach being used. Modality, method and technique—each is addressed to a different level of therapeutic functioning and the sometimes muddled and contradictory statements made about treatment indications may result from a confusion between these three levels. For example, family therapy might be dismissed out of hand because the family seems poorly motivated to come to the clinic; shows little interest in gaining insight into its difficulties and is beset by grave environmental problems of a material nature. What may at first seem a contra-indication for the modality, may turn out instead to be a contra-indication for one of its methods (in this case, the psychoanalytic approach) and an indication for another (in this case, the structural approach). The major part of this annotation is concerned with the current state of discussion regarding indications and contra-indications for the modality not its widely differing methods or technical approaches. A final problem worth mentioning is the fact that few writers have attempted to assess the relative merits of family therapy versus other psychotherapeutic modalities with the same kind of problem, an exception being the work of Wellish et al. (1976). As the report ofthe Group for the Advancement of Psychiatry (1970) points out "the problem is whether there are indeed particular conditions that respond more easily to family therapy than to other forms of treatment". This report found that in considering the indications for family therapy compared with other types of therapy, 83% of questionnaire respondents expressed interest in comparing the outcome of family therapy with various forms of individual psychotherapy, whereas only 47% made a conscious choice between family therapy and any form of group psychotherapy. As regards a comparison with other types of treatment interventions such as behaviour modification, chemotherapy or in-patient treatment, the situation is even bleaker, a notable exception being the work of Langsley et al. (1968), where the effects of family therapy are compared with the effects of hospitalization. A search ofthe literature from approximately 1960 to 1976 is disappointing in that it reveals little in the way of any growing sophistication in its attempts to refine the clinical conditions in which family psychotherapy may appropriately be used. However, with these caveats in mind, some of the approaches that are made to the problem will be considered. THE "EXCLUSIVE APPROACH" POSITION For some, the question of indications or contra-indications simply does not arise. All symptomatology becomes, for these practitioners, amenable to change through the intervention in and manipulation of the individual's most salient psycho-social system—usually his family. Family therapy (or systems therapy as it is more usually described in this generic context) is thus regarded as a new orientation to problems of mental illness and, since systems must be adapted to individuals, not individuals to systems, family therapy or systems therapy is considered to be almost universally appropriate in its application.
ANNOTATION
59
THE "TREATMENT OF LAST RESORT" POSITION
At the other extreme are those who employ family therapy when all other treatment modalities have failed, and the failure of other treatment interventions is hence the criterion for employing family therapy. This approach has meant that family therapy has been tried out in an impressive array of "untreatable situations". Chronic schizophrenia, recidivism, child abuse, drug dependency, have all been exposed to family therapy, the treatment choice being made on the basis of absence of any alternatives. THE "DIAGNOSTIC AID" POSITION
A different view from either of the above, is often adopted by practitioners who are mainly committed to their own discipline and its traditional tools and practices, rather than to the full-time practice of family therapy—be they psychiatrists, social workers or clinical psychologists. Conjoint family interviewing is seen as an aid to promote the more effective use of individual, group or in-patient treatment and is used either initially as a diagnostic aid to treatment selection or as an intermittent event during a crisis phase of therapy—for example, when a child is to be returned to his parents after a period in a children's home. A series of family interviews may be conducted after a schizophrenic patient has returned home in order to maintain his improvement in the community; or a once off conjoint interview may be arranged to try to discover why a successfully treated individual has found that his symptoms have recurred. The selection of family therapy for brief periods is based on the need to unlock intra-psychic or interpersonal resistance which may occur during the course of another treatment modality. THE DIFFERENTIAL TREATMENT POSITION Despite the difficulties discussed in the opening section, this fourth group embraces all those practitioners who endeavour to select family therapy as the treatment of choice from a range of possible treatment interventions. As has already been stated, the criteria used for selection derives more from ongoing clinical experience of "what works" than from hard research findings. One ofthe reasons why comparisons are difficult is that practitioners are working from very different theoretical stances and hence from different basic assumptions, so that categories are often contradictory between one writer and another. Moreover, as with any other type of psychotherapy where the therapist's own self is such a vital ingredient in the therapeutic process, the practitioner will necessarily use very personal yardsticks for drawing up his own list of indications and contra-indications, depending on the type of families and situations with which he knows he can or cannot work. INDICATIONS (1) Symptomatology, of whatever kind which is felt by the practitioner to be embedded in a dysfunctional system of family relationships. Wynne (1965), for example, states that some form of family therapy is indicated "for the clarification and resolution of any structural intrafamilial relationship difficulty". Here the approach is essentially directed towards the family system, with less regard being paid to the presenting symptom as an indicator of whether or not to employ family
60
S. WALROND-SKINNER
therapy. In summary, wherever the identified patient's presenting problems are seen to be expressing the pain or dysfunction of the family system, family therapy automatically becomes the treatment of choice, unless there are specific indications to the contrary.* (2) Clinical situations which are presented transactionally by the patient in terms of a relationship rather than in terms of an individual family member's symptomatology. For example, dysfunctional situations which are presented by one or both parties as marital conflict; difficulties involving sexual dysfunction; relationship difficulties occurring in other intimate interpersonal systems such as unmarried heterosexual or homosexual couples; parent/child or parent/adolescent problems presented as involving the system or sub-system as a whole. Where family members are themselves perceiving their difficulties in relationship terms, it is usually felt to be retrogressive for the practitioner to offer a form of treatment which focuses on one party only. The method or sub-speciality of family therapy chosen may not of course be the treatment of the whole family group on its own. In preference, the practitioner may select conjoint marital therapy (where marital or sexual problems are presented); kin network therapy (where a wide circle of relatives, friends and work associates appear to be intricately involved in the problem); or multiple couples/family therapy (where strong positive or negative transference feelings prevent the therapist from working effectively with the marital pair or family on its own, or where the therapist is felt by the family to be too overpowering, foi example, where the family has a poor sense of group identity (Lacquer, 1972). For some practitioners, multiple couples work is always the treatment of choice for marital problems (Framo, 1973). (3) Family therapy is routinely employed by a large number of practitioners in different types of separation difficulty (although this is also given as a contraindication by some, who feel that individual or stranger group treatment is more appropriate when an adolescent is trying to separate from his family or when a marriage is breaking up). In these situations, individual, group or in-patient treatment may often be employed by the therapist alongside family therapy (Byng-Hall and Bruggen, 1974). (4) Writers working largely from within a psychoanalytic conceptual framework highlight the usefulness of family therapy when membeis of a family are "functioning at a basically paranoid-schizoid level, with part object relationships, lack of ego boundaries and extensive use of denial, splitting and projection" (Skynner, 1969). The rationale used is that in these families, basic psychological features, normally located within the individual, are "scattered" between family members. Hence it is only by assembling the whole group, that the therapist can hope to attend to the various split off and projected intra-psychic attributes of each individual. Family therapy enables individuals to reality test some of their paranoid phantasies, hopefully with positive effect, enabling each to begin to reintegrate the projected negative parts into themselves again. (5) Finally, family therapy has been successfully employed with "hard to reach" disorganized families who would not normally be able to mobilize sufficient re*This would be the traditional position by all the major writers on family therapy.
ANNOTATION
61
sources to enable them to pardcipate in a sustained therapeutic programme. Again, the use of family therapy with low socio-economic, severely deprived families with poor verbal skills is sometimes cited as a contra-indication; but Minuchin et al. (1967) as well as many others have convincingly shown that family therapy, employing an active, directive approach to problem-solving, is often the only intervention that is likely to be effective. CONTRA-INDICATIONS (1) Practical limitations. The physical or psychological unavailability of crucial family members is the first practical consideration for the family therapist to bear in mind. Family members may either be dead, geographically distant or completely unmotivated to engage in any type of therapeutic work. On the other hand, it may be the absence of appropriately experienced and personally suitable therapists that prevents the employment of family therapy in a particular agency or area, even when families seem well motivated and where, from other points of view, family therapy would be indicated. (2) Often family therapy is contra-indicated because the situation has been presented too late to offer the family therapist much hope of bringing about constructive change. In other words, the prognosis may simply be too poor to warrant the necessary expenditure of effort. Ackerman (1966) for example, cites as a contraindication "the presence of a malignant irreversible trend towards break-up of family which may mean that it is too late to reverse the process of fragmentation". Here, of course, those family therapists who engage in divorce therapy would not necessarily agree, though even those would generally admit that the desire to separate relatively undestructively would be a necessary pre-requisite for commencing treatment. (3) The dangers of engaging in family therapy with some families are frequently alluded to, where the emotional equilibrium is so precariously maintained that attempts at changing the relationship system may precipitate a severe decompensation on the part of one or more family members. Many apparently highly stressful interpersonal situations are ego-syntonic for the individuals involved, and attempdng to upset this balance may mean that the last condidon becomes worse than the first (Pittman and Flomenhaft, 1970). It may also be felt to be psychologically dangerous to engage in family therapy where one or more members are organically ill, since the sessions might either increase the level of stress intolerably for that member or might raise unjustifiable "magical" hopes in other family members that the family member's organic symptoms will be removed. (4) Families where one or more members are depressed are often considered to respond poorly to family therapy, since the depressed member may find it difficult to participate meaningfully in conjoint sessions, or to share a therapist. The same rationale may contra-indicate family therapy for severely emotionally deprived individuals. However, in both of these situations the use of individual psychotherapy for the symptomatic members, in conjunction with the conjoint sessions may well enable family therapy to be productive. (5) Finally, it may sometimes happen that the family therapist is asked to take
62
S. WALROND-SKINNER
on the treatment of a family by an agency such as a Court or School and where, unbeknown to the therapist, there is a hidden agenda to be fulfilled (Zuk, 1976). The family therapist may suddenly find himself forced to collude with an external decision-making process where, for example, his prior commitments of confidentiality to the family is called into question by a third party. Families where child abuse is suspected may, for example, involve the family therapist, if he is not extremely careful in making written statements or court appearances in favour of one part of the family against the other—a position which is always inimical to his role as therapist to the whole system. It may ultimately be quite harmful to the family to begin treating these situations via family therapy, where there are severe entanglements between the other agencies involved in the treatment. REFERENCES ACKERMAN, N. W. (1966) Treating the Troubled Family. Basic Books, New York.
BYNG-HALL, J . and BRUGGEN, P. (1974) Family admission decisions as a therapeutic tool. Family Process 13, 443-459. FRAMO, F . (1973) Marriage therapy in a couples group. In Techniques of Family Therapy—A Primer (Edited by BLOCH, D . A.). Grune & Stratton, New York. GROUP FOR THE ADVANCEMENT OF PSYCHIATRY (1970) The Field of Family Therapy, Vol. VII, p. 558.
Mental Health Materials Centre, New York. GuRMAN, A. S. (1973) The effects and effectiveness of marital therapy—a review of outcome research. Family Process 12, 145-170. GuRMAN, A. S. and RICE, D . G . (1975) Couples in Conflict—Mw Directions in Marital Therapy. Aronson, New York. LAcauER, H. P. (1972) Mechanisms of change in multiple family therapy. In Progress in Group and Family Therapy (Edited by SAGER, G. J . and KAPLAN, H . S.). Bruner/Mazel, New York. LANGSLEY, D . G . , PITMAN, F . S., MACHOTKA, P. and FLOMENHAFT, K . (1968) Family crisis therapy—
results and implications. Family Process 7, 145—158. MINUCHIN, S., MONTALVO, B., GUERNEY, B . G . , ROSMAN, B . L . and SCHUMER, F . (1967) Families of
the Slums. Basic Books, New York. PITTMAN, F . and FLOMENHAFT, K . (1970) Treating the doll's house marriage. Family Process 9, 143-155. SKYNNER, A. G. R. (1969) Indications and contra-indications for conjoint family therapy. Int. J. soc. Psychiat. 15, 245-249. SKYNNER, A. G. R. (1976) Om Flesh, Separate Persons—Principles of Family and Marital Psychotherapy. Gonstable, London. STEIN, J . W. (1969) The Family as a Unit of Study and Treatment. Regional Rehabilitation Research Institute, University of Washington School of Social Work. Washington, D.G. WALROND-SKINNER, S. (1976) Family Therapy—the Treatment of Natural Systems. Routledge & Kegan Paul, London. (Ghapter 9 outlines a development in the construction of family taxonomies and gives references to the main attempts which have been made.) WELLISH, D . K . , VINCENT, J . and KELTON RO-TROCK, G . (1976) Family therapy versus individual
therapy: a study of adolescents and ther parents. In Treating Relationships (Edited by OLSON, D. H.). Graphic, Iowa. WELLS, R . A., DILKES, T . G. and TRIVELLI, N . (1972) The results of family therapy: a critical review of the literature. Family Process 11, 189-207. WYNNE, L . (1965) Some indications and contra-indications for exploratory family therapy. In Intensive Family Therapy (Edited by BOSZORMENYI-NAGY, I. and FRAMO, J.). Harper & Row, New York. ZUK, G . (1976) Family therapy: clinical hodgepodge or clinical science? J . Marriage Family Counseling 2, 299-303.
ANNOTATION INDICATIONS AND CONTRA-INDICATIONS FOR THE USE OF FAMILY THERAPY S. WALROND-SKINNER* FAMILY therapy can be defined as the psychotherapeutic treatment of the family system using as its basic medium conjoint interpersonal interviews. It includes many sub-specialities, the most important of which is conjoint marital therapy—which addresses itself to the marital system, in the same way that family therapy focuses on the family system. For the purposes of this annotation, the literature referring to indications for both family and marital therapy will be discussed. A variety of problems confront the theorists who would attempt to define the conditions which indicate or contra-indicate the use of family psychotherapy as the treatment of choice for emotional, psychiatric and behavioural disorders. Not least of these is the immaturity of the subject itself—family therapy having been recognized as a valid psychotherapeutic modality for barely 20 years. Stein (1969) for example, writes of the "experimental, evolutionary and partial quality of most investigations in the family field". Hence it would be true to say that family therapy is still at a "pre-theory" stage of development, with practitioners and researchers simply lacking sufficient experience of their subject to be able to offer anything approaching a definite set of conditions for its use. Empirically based and properly controlled outcome studies into the effectiveness of family therapy are almost entirely lacking (Wells et al., 1972) and whilst work specifically focusing on the outcome of conjoint marital therapy has been rather more widespread (Gurman, 1973; Gurman and Rice, 1975) this too is inconclusive. Lacking too is any established taxonomy of family types which would enable the practitioner to move outside traditional psychiatric nosology into a genuine systems framework of interpersonal disorders (Walrond-Skinner, 1976). The practitioner, working at this pre-theory stage and requiring some guidelines for case selection, develops working metaphors to describe the conditions which appear to him to respond favourably to treatment. Skynner (1976), for example, talks of a "kind of sandwich distribution regarding the suitability for group treatment whereby the most primitive levels of development and the more sophisticated levels could use group situations fruitfully . . . while the level intermediate between these 'top' and 'bottom' levels requires a dyadic relationship". Obviously, such metaphors, arising out of the day-to-day experience of the practitioner, provide fruitful ground for developing hypotheses. The danger arises when apparent confirmation of the metaphor's accuracy occurs subtly over time. It then becomes enshrined not as the product of controlled research, yet inappropriately takes on the status of scientific fact.
•Family Institute, 2 Four Elms Road, Roath, Cardiff CF2 lLE, Wales.
57
58
S. WALROND-SKINNER
A further difficulty needs to be borne in mind. The term family therapy describes a modality, which in turn embraces a complex range of methods, each employing treatment techniques specifically suited to the particular approach being used. Modality, method and technique—each is addressed to a different level of therapeutic functioning and the sometimes muddled and contradictory statements made about treatment indications may result from a confusion between these three levels. For example, family therapy might be dismissed out of hand because the family seems poorly motivated to come to the clinic; shows little interest in gaining insight into its difficulties and is beset by grave environmental problems of a material nature. What may at first seem a contra-indication for the modality, may turn out instead to be a contra-indication for one of its methods (in this case, the psychoanalytic approach) and an indication for another (in this case, the structural approach). The major part of this annotation is concerned with the current state of discussion regarding indications and contra-indications for the modality not its widely differing methods or technical approaches. A final problem worth mentioning is the fact that few writers have attempted to assess the relative merits of family therapy versus other psychotherapeutic modalities with the same kind of problem, an exception being the work of Wellish et al. (1976). As the report ofthe Group for the Advancement of Psychiatry (1970) points out "the problem is whether there are indeed particular conditions that respond more easily to family therapy than to other forms of treatment". This report found that in considering the indications for family therapy compared with other types of therapy, 83% of questionnaire respondents expressed interest in comparing the outcome of family therapy with various forms of individual psychotherapy, whereas only 47% made a conscious choice between family therapy and any form of group psychotherapy. As regards a comparison with other types of treatment interventions such as behaviour modification, chemotherapy or in-patient treatment, the situation is even bleaker, a notable exception being the work of Langsley et al. (1968), where the effects of family therapy are compared with the effects of hospitalization. A search ofthe literature from approximately 1960 to 1976 is disappointing in that it reveals little in the way of any growing sophistication in its attempts to refine the clinical conditions in which family psychotherapy may appropriately be used. However, with these caveats in mind, some of the approaches that are made to the problem will be considered. THE "EXCLUSIVE APPROACH" POSITION For some, the question of indications or contra-indications simply does not arise. All symptomatology becomes, for these practitioners, amenable to change through the intervention in and manipulation of the individual's most salient psycho-social system—usually his family. Family therapy (or systems therapy as it is more usually described in this generic context) is thus regarded as a new orientation to problems of mental illness and, since systems must be adapted to individuals, not individuals to systems, family therapy or systems therapy is considered to be almost universally appropriate in its application.
ANNOTATION
59
THE "TREATMENT OF LAST RESORT" POSITION
At the other extreme are those who employ family therapy when all other treatment modalities have failed, and the failure of other treatment interventions is hence the criterion for employing family therapy. This approach has meant that family therapy has been tried out in an impressive array of "untreatable situations". Chronic schizophrenia, recidivism, child abuse, drug dependency, have all been exposed to family therapy, the treatment choice being made on the basis of absence of any alternatives. THE "DIAGNOSTIC AID" POSITION
A different view from either of the above, is often adopted by practitioners who are mainly committed to their own discipline and its traditional tools and practices, rather than to the full-time practice of family therapy—be they psychiatrists, social workers or clinical psychologists. Conjoint family interviewing is seen as an aid to promote the more effective use of individual, group or in-patient treatment and is used either initially as a diagnostic aid to treatment selection or as an intermittent event during a crisis phase of therapy—for example, when a child is to be returned to his parents after a period in a children's home. A series of family interviews may be conducted after a schizophrenic patient has returned home in order to maintain his improvement in the community; or a once off conjoint interview may be arranged to try to discover why a successfully treated individual has found that his symptoms have recurred. The selection of family therapy for brief periods is based on the need to unlock intra-psychic or interpersonal resistance which may occur during the course of another treatment modality. THE DIFFERENTIAL TREATMENT POSITION Despite the difficulties discussed in the opening section, this fourth group embraces all those practitioners who endeavour to select family therapy as the treatment of choice from a range of possible treatment interventions. As has already been stated, the criteria used for selection derives more from ongoing clinical experience of "what works" than from hard research findings. One ofthe reasons why comparisons are difficult is that practitioners are working from very different theoretical stances and hence from different basic assumptions, so that categories are often contradictory between one writer and another. Moreover, as with any other type of psychotherapy where the therapist's own self is such a vital ingredient in the therapeutic process, the practitioner will necessarily use very personal yardsticks for drawing up his own list of indications and contra-indications, depending on the type of families and situations with which he knows he can or cannot work. INDICATIONS (1) Symptomatology, of whatever kind which is felt by the practitioner to be embedded in a dysfunctional system of family relationships. Wynne (1965), for example, states that some form of family therapy is indicated "for the clarification and resolution of any structural intrafamilial relationship difficulty". Here the approach is essentially directed towards the family system, with less regard being paid to the presenting symptom as an indicator of whether or not to employ family
60
S. WALROND-SKINNER
therapy. In summary, wherever the identified patient's presenting problems are seen to be expressing the pain or dysfunction of the family system, family therapy automatically becomes the treatment of choice, unless there are specific indications to the contrary.* (2) Clinical situations which are presented transactionally by the patient in terms of a relationship rather than in terms of an individual family member's symptomatology. For example, dysfunctional situations which are presented by one or both parties as marital conflict; difficulties involving sexual dysfunction; relationship difficulties occurring in other intimate interpersonal systems such as unmarried heterosexual or homosexual couples; parent/child or parent/adolescent problems presented as involving the system or sub-system as a whole. Where family members are themselves perceiving their difficulties in relationship terms, it is usually felt to be retrogressive for the practitioner to offer a form of treatment which focuses on one party only. The method or sub-speciality of family therapy chosen may not of course be the treatment of the whole family group on its own. In preference, the practitioner may select conjoint marital therapy (where marital or sexual problems are presented); kin network therapy (where a wide circle of relatives, friends and work associates appear to be intricately involved in the problem); or multiple couples/family therapy (where strong positive or negative transference feelings prevent the therapist from working effectively with the marital pair or family on its own, or where the therapist is felt by the family to be too overpowering, foi example, where the family has a poor sense of group identity (Lacquer, 1972). For some practitioners, multiple couples work is always the treatment of choice for marital problems (Framo, 1973). (3) Family therapy is routinely employed by a large number of practitioners in different types of separation difficulty (although this is also given as a contraindication by some, who feel that individual or stranger group treatment is more appropriate when an adolescent is trying to separate from his family or when a marriage is breaking up). In these situations, individual, group or in-patient treatment may often be employed by the therapist alongside family therapy (Byng-Hall and Bruggen, 1974). (4) Writers working largely from within a psychoanalytic conceptual framework highlight the usefulness of family therapy when membeis of a family are "functioning at a basically paranoid-schizoid level, with part object relationships, lack of ego boundaries and extensive use of denial, splitting and projection" (Skynner, 1969). The rationale used is that in these families, basic psychological features, normally located within the individual, are "scattered" between family members. Hence it is only by assembling the whole group, that the therapist can hope to attend to the various split off and projected intra-psychic attributes of each individual. Family therapy enables individuals to reality test some of their paranoid phantasies, hopefully with positive effect, enabling each to begin to reintegrate the projected negative parts into themselves again. (5) Finally, family therapy has been successfully employed with "hard to reach" disorganized families who would not normally be able to mobilize sufficient re*This would be the traditional position by all the major writers on family therapy.
ANNOTATION
61
sources to enable them to pardcipate in a sustained therapeutic programme. Again, the use of family therapy with low socio-economic, severely deprived families with poor verbal skills is sometimes cited as a contra-indication; but Minuchin et al. (1967) as well as many others have convincingly shown that family therapy, employing an active, directive approach to problem-solving, is often the only intervention that is likely to be effective. CONTRA-INDICATIONS (1) Practical limitations. The physical or psychological unavailability of crucial family members is the first practical consideration for the family therapist to bear in mind. Family members may either be dead, geographically distant or completely unmotivated to engage in any type of therapeutic work. On the other hand, it may be the absence of appropriately experienced and personally suitable therapists that prevents the employment of family therapy in a particular agency or area, even when families seem well motivated and where, from other points of view, family therapy would be indicated. (2) Often family therapy is contra-indicated because the situation has been presented too late to offer the family therapist much hope of bringing about constructive change. In other words, the prognosis may simply be too poor to warrant the necessary expenditure of effort. Ackerman (1966) for example, cites as a contraindication "the presence of a malignant irreversible trend towards break-up of family which may mean that it is too late to reverse the process of fragmentation". Here, of course, those family therapists who engage in divorce therapy would not necessarily agree, though even those would generally admit that the desire to separate relatively undestructively would be a necessary pre-requisite for commencing treatment. (3) The dangers of engaging in family therapy with some families are frequently alluded to, where the emotional equilibrium is so precariously maintained that attempts at changing the relationship system may precipitate a severe decompensation on the part of one or more family members. Many apparently highly stressful interpersonal situations are ego-syntonic for the individuals involved, and attempdng to upset this balance may mean that the last condidon becomes worse than the first (Pittman and Flomenhaft, 1970). It may also be felt to be psychologically dangerous to engage in family therapy where one or more members are organically ill, since the sessions might either increase the level of stress intolerably for that member or might raise unjustifiable "magical" hopes in other family members that the family member's organic symptoms will be removed. (4) Families where one or more members are depressed are often considered to respond poorly to family therapy, since the depressed member may find it difficult to participate meaningfully in conjoint sessions, or to share a therapist. The same rationale may contra-indicate family therapy for severely emotionally deprived individuals. However, in both of these situations the use of individual psychotherapy for the symptomatic members, in conjunction with the conjoint sessions may well enable family therapy to be productive. (5) Finally, it may sometimes happen that the family therapist is asked to take
62
S. WALROND-SKINNER
on the treatment of a family by an agency such as a Court or School and where, unbeknown to the therapist, there is a hidden agenda to be fulfilled (Zuk, 1976). The family therapist may suddenly find himself forced to collude with an external decision-making process where, for example, his prior commitments of confidentiality to the family is called into question by a third party. Families where child abuse is suspected may, for example, involve the family therapist, if he is not extremely careful in making written statements or court appearances in favour of one part of the family against the other—a position which is always inimical to his role as therapist to the whole system. It may ultimately be quite harmful to the family to begin treating these situations via family therapy, where there are severe entanglements between the other agencies involved in the treatment. REFERENCES ACKERMAN, N. W. (1966) Treating the Troubled Family. Basic Books, New York.
BYNG-HALL, J . and BRUGGEN, P. (1974) Family admission decisions as a therapeutic tool. Family Process 13, 443-459. FRAMO, F . (1973) Marriage therapy in a couples group. In Techniques of Family Therapy—A Primer (Edited by BLOCH, D . A.). Grune & Stratton, New York. GROUP FOR THE ADVANCEMENT OF PSYCHIATRY (1970) The Field of Family Therapy, Vol. VII, p. 558.
Mental Health Materials Centre, New York. GuRMAN, A. S. (1973) The effects and effectiveness of marital therapy—a review of outcome research. Family Process 12, 145-170. GuRMAN, A. S. and RICE, D . G . (1975) Couples in Conflict—Mw Directions in Marital Therapy. Aronson, New York. LAcauER, H. P. (1972) Mechanisms of change in multiple family therapy. In Progress in Group and Family Therapy (Edited by SAGER, G. J . and KAPLAN, H . S.). Bruner/Mazel, New York. LANGSLEY, D . G . , PITMAN, F . S., MACHOTKA, P. and FLOMENHAFT, K . (1968) Family crisis therapy—
results and implications. Family Process 7, 145—158. MINUCHIN, S., MONTALVO, B., GUERNEY, B . G . , ROSMAN, B . L . and SCHUMER, F . (1967) Families of
the Slums. Basic Books, New York. PITTMAN, F . and FLOMENHAFT, K . (1970) Treating the doll's house marriage. Family Process 9, 143-155. SKYNNER, A. G. R. (1969) Indications and contra-indications for conjoint family therapy. Int. J. soc. Psychiat. 15, 245-249. SKYNNER, A. G. R. (1976) Om Flesh, Separate Persons—Principles of Family and Marital Psychotherapy. Gonstable, London. STEIN, J . W. (1969) The Family as a Unit of Study and Treatment. Regional Rehabilitation Research Institute, University of Washington School of Social Work. Washington, D.G. WALROND-SKINNER, S. (1976) Family Therapy—the Treatment of Natural Systems. Routledge & Kegan Paul, London. (Ghapter 9 outlines a development in the construction of family taxonomies and gives references to the main attempts which have been made.) WELLISH, D . K . , VINCENT, J . and KELTON RO-TROCK, G . (1976) Family therapy versus individual
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