Goal Setting

Family therapy is an active therapy. Early in treatment, the therapist works to define the presenting problem, the people involved with the problem, the interpersonal patterns of behavior related to the problem, and the criteria by which each family member would know if the therapy is successful. Goal setting becomes a group activity, with the therapist working to help the family negotiate common achievable goals in their own words. This is not so easy. (If it were, the family would likely not need therapy!) Sometimes, goal setting can take several sessions because family members do not agree on the definition of the problem or the desired outcome. Also, many times initial goals are framed in unachievable terms.

Sonia, for example, stated that her goal for couples therapy was to have her husband, Reynolds, never express anger with her. Therapy then focused on psychoeducational principles that normalize anger so an appropriate goal focused instead on how Sonia wishes Reynolds to express his anger to her.

Enactment

In many psychotherapies, patients talk about other relationships and problems. In family therapy, these relationships and problems are brought into the room. After setting a goal about dealing with anger, the therapist asked Reynolds to show how he acts when he’s angry with Sonia. “Assume that you had a bad day at work. Then think of something that Sonia does that is sometimes irritating. Turn to her and show me what happens when you’re angry.”

The in-session enactment allows the therapist and the patients to witness the problem firsthand. The patients can then reflect on the experience, and the therapist can coach them on alternative ways of communicating. “Try telling Sonia when you come in the door: ‘Honey, I had a stressful day at work. Let me tell you about it.’ Monitor your own internal experience to make sure that you don’t take out your difficult day on the person you love the most.” After the couple tried out this new way of communicating, the therapist advised, “When expressing your feelings about an irritating habit, be sure to start with: ‘When you leave your work-out clothes on the floor, it makes me angry. I feel like you want me to do all the cleaning up in the house, even though we both have outside jobs.’”

Circular Questions

Family therapists use interview techniques that reveal the nature of relationships in the family (Selvini-Palazzoli et al., 1980). One of those techniques, called circular questions, sometimes brings to light longstanding misunderstandings.

Therapist: Sonia, when Reynolds leaves his clothes on the floor, what is he trying to communicate to you?

Sonia: He wants me to become a better housewife. He’s hoping I’ll do his chores as part of that. But I’m not!

Reynolds: [looking shocked] This is not a test of your skills! I’ve always been sloppy in the bedroom. I need to change that now that I have a roommate.

Externalizing the Problem

A family therapy technique introduced by Michael White (White & Epston, 1990) moves the problem outside of one individual or one relationship. Externalizing the problem reduces blaming behavior that can prevent the problem from being resolved.

Bill and Stella came for therapy because Stella was having recurrent spells of blanking out. At first her physician thought she might have epilepsy, but long-term monitoring in the hospital revealed that these spells were psychogenic in origin. The neurologist thought their timing was related to marital stress and referred the couple for therapy. In the second session, after setting goals that included reducing the blanking out spells and improving their marriage, the therapist asked Stella and Bill to consider these spells as something external to both of them.

“What do the spells look like?” the therapist asked. “What color are they? Do they have a name? Are they like an animal, a plant, a person?”

Stella and Bill had surprisingly little disagreement about the nature of the spells. Stella said they were red, “hot like a fire.” Bill agreed, adding they were “like a red porcupine, all sharp and bristly.” These descriptions gave the therapist valuable information about the possible relationship of these spells to anger in the relationship. When she asked about a name for this porcupine, Stella said, “Porky.”

To some extent this exercise served to desensitize both members of the couple to talking about the spells, which had heretofore been mysterious and somewhat scary. The therapist then set about to find out when Porky was likely to come on the scene and to slowly help the couple learn to identify their anger and express it appropriately. Two sessions after externalizing this symptom, Stella revealed that Bill was sometimes emotionally abusive to her. Her Catholic faith, she felt, did not permit her to express anger back. She now noticed that Porky tended to appear in reaction to Bill’s emotional tirades. Over time, Bill was placed on antidepressants as an aid to learning self-regulation skills. As his verbal abuse eased, Stella’s blanking spells stopped altogether. Both continued to work on communication and anger management.