It was already a truism in mental health circles more than sixty years ago: when a “problem” child is brought for therapy, and progress is made, clinicians may expect the parents to withdraw the child from therapy prematurely.

The explanation: when a child changes, this upsets the former equilibrium of the family system, and the parents don’t like it.  The child was the “index patient,” but it also reflected some problem elsewhere in the family, which other family members did not want to address.  This is the approach of family therapy, whereby both children and adults are seen as parts of a system of interlocking personalities, who relate partly as interacting members of a small social system with its own rules, taboos, and rewards – which often don’t get talked about.  Now, to be sure, there are many more or less healthy families who have fairly functional family systems.  But all families are organized around certain private as well as public and verbalized intentions, loyalties, and avoidances.

Two additional kinds of analysis can be useful in understanding a family’s dynamics (in addition to the several theories of family interaction).

One is the perspective of family themes. Some families may see themselves in terms of a single overarching idea: “We are a family that . . . always succeeds . . . [or]. . .  never gets out of debt.”  Family members may verbalize it, or just silently recognize its dominance.   And a theme can continue for three or more generations.

A second perspective views families as either stable or unstable, and also as either satisfactory or unsatisfactory. The stable satisfactory family may need only some short term help at a time of transition – a basically healthy family.  The unstable but satisfactory family may exhibit genuine love but members may lack basic skills of communication and conflict management.  The unstable unsatisfactory family contains fewer positive resources and tends to fragment, so it may need extra help. Finally, the stable unsatisfactory family is locked into a bad pattern and is the hardest to treat.  Examples are the alcoholic with an enabler partner, and the situation of incest.

Families are about couples, too.  Troubled couples bring the baggage of their separate childhood emotional lessons into the therapy room.  A man may have molded himself to be like his father, or perhaps the opposite.  A woman may choose a man who in some way resembles her father or carries the promise of a very different relationship.  A sibling may have been a rival or a burden.  These lessons, hopes, and fears may be fairly easy for the therapist to discern, but more difficult to influence.  The conflict between the couple often involves their learned reactions toward both their parents, and toward the kind of conjugal relationship their parents maintained.  Some couple therapists say there are at least six people in the room.

Various theories may recommend either a slow and indirect approach, or direct interventions into the conflict.  If young couples can be engaged in good therapy early in their conflict, improvement may come readily. Initially, some partners may come to appointments on the defensive, or convinced of their own righteousness and wishing to enlist the therapist as an ally; either way, they can be difficult to engage, and require our greatest sensitivity.  When couples postpone therapy until their conflict has gone on for years, sometimes they can still be helped in therapy toward a relationship of greater intimacy.  It’s often helpful to ask, “If your partner were gone, what would you miss most?”

Even in individual therapy, if the client/patient is preoccupied with a problematic relationship, it’s useful to examine the regular patterns of interaction with that person, and discover how each person operates to maintain that pattern.  Every individual who comes for therapy has a family in her/his background, even if the parents are long gone, or are unknown to an adoptee patient/client.  This person may still have old fantasies — wishes and resentments about those lost parent figures — which may influence the person’s present attitudes and behavior.

Therefore, whether there are individuals, couples or families in therapy, a comprehensive therapeutic focus includes looking at not just separate personalities but also the characteristic ways people treat each other, i.e., the small-group predictable patterns of their interactions.

Finally, when a therapist who’s dealing with a distressed relationship can dig deeply, or provide a sufficiently accepting environment, the starkest feeling of all may then emerge: “You don’t love me any more!”  The mixture of desperation, hurt, anger, and fear that this communicates is what makes relationship therapies so challenging – but we can offer hope and help, to work with this basic human longing for a loving connection.

David C. Balderston, Ed.D., LMFT

New York City

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