Multiple Family Therapy

Multiple Family Therapy:

General Systems Theory and

Intervention Strategies*

By Paul K. Thorington, Ed.D.

Robert Reimondi, M.A.

Paul K. Thorington, Ed.D.

ABSTRACT

This paper presents Multiple Family Therapy (MFT) according to General Systems Theory and describes specific intervention strategies and techniques. The purpose is to give an outline of Multiple Family Therapy theory to assist in conducting sessions and to better understand group and family interaction in the Multiple Family Therapy process. The focus is on Multiple Family Therapy and General Systems Theory as they are used and understood to form a theory of family process and change that can inform intervention strategy and technique.

* Based on a paper presented at the AAMFT Annual Meeting and First International Conference, Toronto, Ontario, November, 1980.

Multiple Family Therapy, (MFT) the simultaneous treatment of two or more families by one or more therapists, was pioneered in 1950 with the work of H. Peter Laqueur and colleagues at Creedmoor State Hospital in New York. Since its beginnings as a treatment of families of patients hospitalized for major psychiatric disorders, MFT has been used in a widening arena of clinical populations and specific problem areas.

Laqueur (1980, 1972 a) has described groups of approximately five multi-generational families. These groups are open-ended, and heterogeneous in terms of diagnosis of the identified patient and socio-economic background. Multiple Family Therapy groups usually have co-therapists and often observers and video camera operators.

Historically, MFT can be seen in many ways to coincide with the development of the Family Therapy Movement in general (Benningfield 1978) as well as independently maintaining its unique strategic and theoretical perspective. Currently, the literature on MFT has not been extensive. On a relative scale, MFT has been observed to be in an early stage of theoretical development with Laqueur being generally recognized as the founder and major theorist in the field (Strelnick 1977).

Multiple Family Therapy is based on the interactional approach to human behavior and has been conceptualized according to General Systems Theory (Laqueur 1980, 1977). According to this understanding, families are conceptualized as systems composed of individual members and alliances such as parents vs. children or male vs. female members. Families, as total systems, may fail to function by virtue of breakdown in the ability to operate as an integrated family unit. The goal of MFT is to improve internal structure in families as well as mutual understanding and communication (Laqueur 1980).

Interactional Approach to Human Behavior

The interactional approach has been described by Don Jackson (1965). It is an interpersonal orientation that focuses on present ongoing relationships as they perpetuate and maintain behavior. Several major concepts are essential to a working understanding to the interactional approach. These concepts are: behavior as communication, circular causality, multi determination of behavior and the law of equifinality.

All behavior is a form of communication and it has been maintained that “one cannot, not communicate”. This viewpoint emphasizes that behavior conveys meaning and information and is carried out on verbal, non-verbal or kinesic, and meta levels of communication in an interpersonal context. The principle of circular causality is contrasted to that of linear causality. While linear causality observes that A leads to B, it ignores that B’s occurrence may influence the occurrence of A in the first place. According to circular causality then, every behavior or act is simultaneously a stimulus, response and reinforcer. This principle states that behavior is influenced by multiple factors and to identify only one is to ignore other equally important determinants of behavior. Therefore it cannot be said that A leads to B but rather that perhaps it is A, C, D, etc. that contribute to B. Also important to note in this regard is the difficulty in explaining present behavior totally in terms of past events simply because of the extreme difficulty in comprehensively identifying all salient historical variables. The final concept of the interactional approach to be discussed here is what is referred to as the law of equifinality. This principle states that different causes may lead to similar results. An example of this would be that two different sets of family interactional patterns may both be associated with bed wetting, truancy, abuse, or various psychiatric disturbances.

General Systems Theory

The interactional approach to human behavior is conceptualized according to General Systems Theory. General systems theory has at least four major components: organization, control, energy, and time and space (Steinglass, 1978). Organization refers to wholeness, boundaries, and hierarchy of system. The whole is conceptualized as being greater than the sum of its parts; and as being independent of its parts. Rather than looking at the individual elements, the focus is on the arrangements between the elements. Emphasis is on the interdependency of the elements and the relationship between them. The nature and quality of relationships between the elements of a system are conceptualized in terms of boundaries. These are defined according to their permeability or the ease with which energy and information passes between two elements or systems. For example, we may talk of the spouse subsystem in a family as it is able to maintain appropriate boundaries between itself and the child

sub-system. The third element of the organization of a system is that of hierarchy. This refers to the pecking order in a system or family. Pecking order is the organization of a system according to the perceived status of the elements (or individuals) in that system (or family). In this regard, it is important to note that any group (such as a family) cannot not organize; there has to be a hierarchy, however elusive it may be to observe according to perceived status and control. Common to most family therapists are the notions of hierarchical, democratic or laissez -faire organizations in families.

The second element of General Systems Theory is that of control. This is conceptualized in terms of homeostasis and feedback. Homeostasis of a system is determined by the system’s tendency toward equilibrium and transformation. Feedback mechanisms determine which tendency is emphasized in a system at any given time. Negative feedback is deviation counteracting and supports the tendency toward homeostasis with things remaining the same. Positive feedback is deviation amplifying and supports transformation and change.

The third element in General Systems Theory is that of energy. All living systems (such as families) come into being, serve a function, and then cease to exist. Energy is required to keep a system growing and functioning. Regarding systems, energy is exchanged across and between subsystem boundaries at interfaces. Energy entering a system is viewed as serving to organize that system (negentropy) or as supporting or leading to chaos or disorganization of that system (entropy). As such, energy entering a system is required for a system to survive and grow, but it can also serve to destroy or impair functioning of a system. As a system, a family has many contacts (or interfaces) with other systems or subsystems that provide energy into the family. Extended family groups; agencies such as welfare or community mental health centers; government; and society all affect the family through the energy they provide and information they communicate to a family. This energy keeps the family alive while also influencing its organization.

The fourth element of a system is time and space. This element is especially important because of the other elements of a system are viewed as operating in these time and space dimensions. The time dimension refers to the living, changing, ongoing process of interaction and exchange of energy. The time dimension emphasizes the evolutionary process attending to history in terms of the past, present, and future. The space dimension refers to the here and now aspects of interaction according to

spatial cues of distance, size, etc. This tends to be a more static conceptualization of human behavior.

As previously mentioned, elements of a system are conceptualized according to temporal and spatial dimensions. Organization, when viewed spatially, is referred to as structure. For example, when referring to an individual’s behavior, while focusing on the dimension of time we speak of rules in a family. We use the term role when we attend to the dimension of space. Control conceptualized according to the time dimension can be viewed as problem-solving; a family’s ability to adapt to demands and stresses placed on it according to its stage of development of growth. Feedback, as an ongoing process, is a major aspect of the family’s problem-solving skills. Spatially, control is whether or not the system is in a state of homeostasis or equilibrium. Also, feedback is conceptualized as a mechanism generally referred to as a feedback loop. Energy conceptualized according to the temporal dimension is communication. Energy according to the spatial dimension is conceptualized as the interfaces between subsystems. Communication occurs across and through these interfaces.

Multiple Family Therapy

Multiple Family Therapy conceptualization to date, highlight some elements of General Systems Theory more than others. In MFT, organization is conceptualized spatially. Emphasis is on the structure of the family with a focus on the boundaries that exist between individuals. Families are conceptualized as systems that have subsystems while simultaneously being parts of a larger supra-system. For example, spouses are a subsystem of a family and a family is a subsystem of society. Family rules are viewed according to roles that people act out in their family. Regarding control, the emphasis is on the temporal dimension and how well problem solving supports mutual understanding and cooperation between family members. The focus is on feedback mechanisms and problem-solving skills. Multiple Family Therapy tends to focus on the temporal dimension as conceptualized by the communication between subsystems. The MFT therapist focuses on communication across the boundaries of subsystems while considering the interfaces between the individual, nuclear family, extended family, society, and beyond as is feasible.

MFT Theory of Process and Change

The elements of General Systems Theory that MFT emphasizes serve to determine a theory of family process and change for MFT. In MFT pathology or problems-in-living are viewed as occurring at interfaces of subsystems. Family problems are interface problems (Laqueur, 1972) because it is as these interfaces between subsystems that decision-making and problem-solving is required. Problems may or may not arise depending on how well the family is able to adapt to stresses that affect its organizational structure. Problems arise if individuals or family members cannot adapt to a new situation.

Regarding change, MFT therapists focus on what it is that constitutes a therapeutic system. The focus is on reorganizing the family structure so that family interactions will change with communication across interfaces improving. This improvement then leads to improved decision-making and problem-solving for the family. The final goal of therapy is mutual understanding and cooperation between family members, i.e. to improve their problem-solving skills.

MFT Mechanisms of Change

What causes a family to re-organize in this manner? Multiple Family Therapy hypothesizes at least eleven mechanisms of change (Laqueur, 1972). The first of these is the USE OF FAMILIES AS CO THERAPISTS. Less disturbed families are used by the therapist to reach and help more disturbed families. The exchange of ideas, sharing of similar experiences, mutual problem-solving and lending of support to each other helps families change. Families are taught to help each other to deal with everyday problems-in-living. The second mechanism of change is that of COMPETITION. Threat to a family’s status stimulates competition between families in MFT. This results in family members becoming motivated to achieve the desired change in their family dynamics. The third mechanism of change is called the DELINEATION OF THE FIELD OF INTERACTION. Multiple Family Therapy process helps family members look at the individual in terms of his or her family and other systems such as neighborhood and society. As a result, problems are understood in the context of the total field of interaction. The focus is on how one person affects another and on how each person reacts in, and is reacting to, the many subsystems to which she/he belongs. The fourth mechanism of change is LEARNING BY ANALOGY. This occurs in MFT when family members observe analogous situations in other families and apply them to similar situations in their own family. This mechanism of change can be viewed as the therapist’s “setting up mirrors” to teach families about themselves. The fifth mechanism that produces change in MFT is LEARNING THROUGH IDENTIFICATION. This focuses on the fellowship of experience as one person identifies with another person according to role, problems, etc. Similar to this is the sixth mechanism of change which is LEARNING THROUGH THE IDENTIFICATION CONSTELLATION. This is a mechanism of change that is unique to MFT and occurs when families members learn something about their own behavior when they identify with other families that have similar or identical family structures, e.g. Two families that are both comprised of two parents, one son, and two daughters. The seventh mechanism of change is referred to as “TUNING IN”. This occurs when members of the MFT group identify one situation with another. Observing other families allows families to recognize patterns of behavior in their own family. By observing these patterns in other families, family members are able to focus in or “tune-in” on the family interaction patterns in their own families. The eighth mechanism of change is LEARNING THROUGH TRIAL AND ERROR. Members of an MFT group are able to try out new behavior in the safe atmosphere of the group. The group provides support for, and feedback on, new problem-solving strategies. The ninth mechanism that is said to facilitate change in families in MFT is. THE USE OF MODELS. More appropriate and satisfying ways of behavior in one family are used as examples for other families. This serves to challenge, as well as, to motivate other families to attempt new, more productive means of interacting. The tenth mechanism of change is referred to as the “FOCUS OF EXCITATION”. This is derived from information theory which states that events which have the least probability of occurring, and yet do occur, have the greatest information value. New behavior exhibited by a group member is often used by a therapist to focus discussion and facilitate change in other group members. The eleventh mechanism of change is known as AMPLIFICATION AND MODULATION OF SIGNALS. A sensitive member can pick up a signal from the therapist and amplify it, thereby sensitizing the family to an issue. This family can then do the same for other families in the group. The therapist’s intervention is facilitated and amplified by some group members, thereby potentially having greater impact on all present.

MFT Intervention Strategies

It is important to note that these mechanisms of change may also be employed to inform intervention strategies which the therapist uses to determine the appropriate intervention technique prior to and during the therapy sessions. The mechanisms of change or strategies can be summarized for heuristic purposes , as the three C’s or MFT: Comparison, Cooperation and Competition. All MFT mechanisms of change or strategies can be included in one of these three process categories. For example, regarding Comparison, the therapist might focus on family members and their families with the focus being on similarities, analogies, and identification. Regarding Cooperation between family members, the therapist would facilitate group members in assisting one another, lending encouragement, modeling appropriate behavior, and giving one another feedback about behavior. The third C of MFT intervention is Competition in which the therapist would facilitate competition to motivate and challenge group members to change and try new behaviors.

These mechanisms of change or intervention strategies are modified by, as well as modify, the three stages through which most MFT can be viewed as follows: (1) initial relief phase; (2) resistance and working through phases; and (3) the improvement phase in which openness and increased confidence is exhibited. These phases are stages that an MFT group passes through over time (i.e. between sessions). Borrowing from Haley (1976), each individual session may also be divided into four separate stages. These stages are the: (1) social stage, in which the therapist makes family members welcome; (2) problem definition stage, in which the problem is defined; (3) working through the problem stage, in which an attempt is made to solve the presenting problem; (4) and, the summary stage in which the session is reviewed and a task assigned. When we look at the course of treatment of an MFT group we consider the phases across the sessions and the stages within each individual session. Intervention techniques used by the therapist are a function of the strategies or mechanisms of change and of the phases and stages of treatment. The MFT therapist acts as a systems analyst and :orchestra conductor” of family interaction in the group session. She/he analyzes the MFT system and its families according to their structure, feedback mechanisms at interfaces, and phase of treatment. The focus is on: boundaries and roles; stresses with which families need to deal; and, problem-solving skills. Once this systems analysis is made the therapist acts to facilitate mechanisms of change to inform family systems, thus providing alternative skills and growth opportunities.

MFT Intervention Techniques

To be familiar with a theory of interaction, systems, process, and change the MFT therapist is better prepared to attempt to facilitate changes within the group. What follows are just some ways in which the MFT therapist may chose to intervene in a session, considering all the factors previously discussed.

The first technique described is the use of focused discussion groups determined by family roles (Laqueur 1976). This technique involves having all the mothers – wives coming to the center of the group in a “fish bowl” fashion and discussing how they feel about and perceive their role in their family. In a similar manner this can be done with all the fathers, sons, daughters, “good guys” – “bad guys” etc. After this is done it can be used as a vehicle for group feedback and further discussions and interventions. This technique focuses on system boundaries and roles. The mechanisms of change conceivably involved with this technique might be learning through identification, competition, and the use of models. Regard timing, this technique might be used with a new group or when a new family joins the group. It may also be of use when the group has seemed to focus on certain issues such as parenting or marital roles.

Another technique is the use of videotape feedback. This involves showing families their interactions on the video monitor with the group discussing their behavior and giving feedback. It is often revealing to turn down the audio in order to focus on nonverbal elements of family and group interaction. Needless to say this technique is equally helpful for therapists in observing their own interactions in the group. This technique is useful in promoting the use of such mechanisms as learning by trial and error, tuning in, and the use of families as co-therapists. It must be noted here that some degree of expertise in introducing videotape to the group is required and desensitizing both client families and therapists to their own images and perceptions of themselves is crucial (Metcoff 1980).

Family Sculpting has been used extensively in Family Therapy and is of unique value in the MFT group. Family members are asked to sculpt their families as they perceive them structurally and in terms of proximics. Often times this is done attending to the temporal dimension as family members sculpt their family over a period of time, ie. Five years ago, ten years ago, at an important anniversary, etc. Often it is of great therapeutic value to have members sculpt the family the way they would like it to be. Very often key family members are absent from the group or deceased, in many situations it is productive to have members of other families or observers, “stand in” for these absent members. After the sculpting has taken place the entire group can discuss and give valuable feedback, as well as get more in touch or aware of their own family patterns. Sculpting in the MFT group involves such mechanisms as delineation of the field of interaction, learning through identification and identification constellation, and the use of models. This technique may be used with a new group or when a new family enters a group. It may be repeated over time and specific family interactions such as breakfast time can be sculpted as well as historical and structural material. Sculpting has also been used to make assessments and comparisons of how families have progressed over time in treatment.

The last techniques discussed here are what may be called the “Yes- No” exercise and the “Back to Back” exercise (Laqueur 1976). In the first exercise, members of families (eg. Husband-wife, parent-child) are asked to pair off and stand facing each other. Members place their hands on each others shoulders keeping arms and legs locked in position. One member is told to repeat the word yes and the other the word no. As participants repeat this louder they are asked to push along with the verbalization for a period of time controlled by the therapist. The technique is effective in conflict resolution and problem solving. There is seldom a clear cut “winner” as the rules serve to equalize power and most arguments boil down to yes - no situations. The second technique requires that two family members stand with only their backs touching. They are then asked to nonverbally do something to change this position. How each person deals with this task can provide valuable information on how distance is maintained in conflict situations. The group can also provide valuable feedback on alternative ways such a situation may be dealt with. Both of these techniques involve learning by analogy and often trial and error. They can be used in the ongoing group process or around particular issues.

The above paragraphs have described several areas of techniques which may be used in MFT. Clearly, numerous others have ,could and will be adapted for usage in the overall group facilitation. As in other therapies, the uses of techniques reflect the competence and self-confidence of the therapists as well as a proper sense of timing and direction and clinical discernment of propriety.

In summary, when conducting MFT the therapist focuses on the intra-session stages and inter-session phase of group process. A large percent of change within families goes on between sessions and needs to be accounted for by the treatment team . The therapist is also mindful of individual family structure (e.g. feedback mechanisms, boundaries and interfaces) in addition to problem solving skills and communication style. Multiple Family Therapy theory of of process ,change and mechanisms of change are used to intervene with appropriate therapeutic techniques.

This can only be seen as a general outline of some of the major features of Multiple Family Therapy and its reliance of General Systems

Theory for “navigation”. Clearly the training of multiple family therapists requires role playing, observation, study, supervised experience and is an ongoing enterprise even for experienced clinicians in this evolving modality of treatment.

H. Peter Laqueur, MD

REFERENCES

1. Benningfield, A.B., Multiple Family Therapy systems. Journal of Marriage and Family Counseling, 1978, 4, 25-34

2. Haley, J., Problem Solving Therapy, San Francisco: Jossey-Bass, 1976

3. Jackson, D.D., The Study of the Family, Family Process, 1965, 4, 1-20

4. Laqueur, H.P., LaBurt, H.A., and Morong, E., Multiple Family Therapy: Further Developments. In J. Haley (Ed.) Changing Families, New York: Grune & Stratton, 1971

5. Laqueur, H.P., Mechanisms of Change in Multiple Family Therapy. In C.J. Sager and H.S. Kaplan (Eds.) Progress in Group and Family Therapy. New York: Brunner/Mazel 1972b

6. Laqueur, H.P., Multiple Family Therapy, In A. Ferber, M. Mendelsohn, and A. Napier (Eds.) The Book of Family Therapy. New York: Science House, 1972a

7. Laqueur, H.P., Multiple Family Therapy. In P.J. Guerin (Ed.) Family Therapy: Theory and Practice, Englewood Cliffs: Prentice hall, 1976

8. Laqueur, H.P., Family Therapy (Multiple) and General Systems Theory. In International Encyclopedia of Psychiatry, Psychology, Psychoanalysis and Neurology, Aesculapius Publishers, Inc., 1977

9. Laqueur, H.P., Multiple Family therapy. In R. Herink (Ed.) The Psychotherapy Handbook, New York: New American Library, 1980

10. Metcoff, J. Introducing Videotape to the Family in the Role of a Specialized Member of the Treatment Systems, Journal of Marital and Family Therapy, 1980, 6, 153-158

11. Steinglass, P., The Conceptualization of Marriage from a Systems Theory Perspective. In T.J. Paolino and B.S. McCrady (Eds.) Marriage and Marital Therapy. New York: Brunner/Mazel, 1978

12. Strelnick, A.H., Multiple Family Group Therapy: A Review of the Literature. Family Process. 1997, 16, 307-325

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