Family and marital therapy

Psychiatric symptoms are often exacerbated by a dysfunctional relationship between marriage partners, or within a larger family group. Common problems include the following:

• scapegoating, in which one family member is automatically blamed for problems

• extremes of authority and dependency

• ambiguous communication styles

• family secrets

• gratification of one person through the illness of another

• a shared stress, such as bereavement, affecting the whole family.

'Systems theory' has been influential; it views the family as a self-contained system, in which changes in one element are compensated for by complementary changes in others. Thus, problems in one family member can be addressed not only directly, but also by changing the response of the others.

There are various types of family therapy; systemic therapy has been influential: the family is seen as a self-contained system, whereby a change in one member, by a process of feedback, is bound to affect other members. Strategic therapy emphasizes the role of the therapist in designing and evaluating the effects of therapy.

Recent trends within society, such as the replacement of traditional marriage by 'serial monogamy', more mothers working outside the home, more men unemployed, and fewer older people in close contact with their children and grandchildren, have influenced the type of presenting problems and expectations of outcome.

Therapy involves regular meetings between family members and therapist(s). As with group therapy, a particular technique can be adopted, but general principles include:

• encouraging clear communication between family members

• setting practical goals agreed by all parties

• emphasizing positive aspects of relationships and encouraging rewarding behaviour

• discouraging criticisms, especially repetitive ones about the past.

Role-play may be used to enable better appreciation of others' points of view.

Good motivation by all participants, and a reasonable degree of goodwill and honesty between them, are prerequisites for success and the therapists should avoid taking sides.

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