Dr. John Sargent and Dr. Ronald Leibman, who worked with Salvador Minuchin at the Philadelphia Child Guidance Clinic, have divided family therapy into three phases. In the initial phase, we evaluate the patient and the family and establish the therapeutic relationship. For low-weight anorexic patients, we devise a contract that identifies the problem, then spells out in specific terms the treatment’s goals and the methods for achieving them. The contract usually focuses on the patient’s weight; we hold off dealing with other problems, such as marital difficulties, until a later time. The first thing is help the anorexic gain weight, or the bulimic to break her binge-purge cycle, and improve her psychosocial skills.
During the assessment, we get the facts: ages, educational level, and the nature of the family’s social interactions. We also want to know how each member perceives and defines the problem. What factors affect the situation: physical illness, social issues, religion? What was the family like before the illness? What stressors triggered the problem? Who is closest to whom? Is there an extended family – grandparents, for example? Who outside the family plays important roles in their lives? Teachers? Friends? Employers?
We then probe a little deeper. What are the patterns of interaction: Who communicates with whom? Are some family members “friends” and others “enemies”? How strong is the marriage? Is the couple satisfied? Do they agree on parenting strategies? How flexible is the family – are roles rigidly laid out? Are members oversensitive to each other, or detached and distant? How strong are their social networks? Are there financial or other medical problems? Do the children have family responsibilities that fit their stage of development? To what extent is the family aware of the illness? What are its fears, beliefs, and attitudes about it? The middle phase of treatment begins once the symptoms are more under control. We now shift our focus to the patient’s problems with her emotional and physical development, especially as they relate to unresolved family conflict. We identify the stresses that might have led to the weight loss or bulimia, and find other ways of dealing with them. It helps if we can relate symptoms to family processes -for example, seeing that a binge might occur if the patient feels unloved or pressured in some way.
It often happens that as the patient gains control she experiences a flood of new feelings. A little success might bring up fears about handling new tasks. We caution family members to expect that their daughter or sibling might have feelings of depression, or of ineffectiveness and rejection. If we’re not careful, the family might focus on these new problems and become even more enmeshed than before.
During this second phase, we help the family learn how to tolerate open conflict, and show them new ways of resolving problems. We stress that the patient’s separation from the family is an inevitable and healthy process – but perhaps a painful one for everyone involved. It helps if the parents learn to deal with each other directly. Once they do, the patient will feel less protective and can work on her relationships with her friends. As Richard Schwartz puts it, she can “grow up” without having to “grow away.”
This second stage is critical, since it marks the transition from focusing on the disorder itself to focusing on the broader issues. When therapy is working, everyone wins. The parents learn new ways of helping their daughter grow; the patient shows she can take responsibility for herself and that she has earned the right to “declare independence” from her family.
In the final phase, we work to “wean” the family from therapy. If we have identified problems that still need work – the parents’ marriage, for example – we steer people toward therapy designed to address those issues. At this point, the patient’s individual therapy might focus on how she can change the way others in her family treat her, to keep harmful interactions to a minimum. Just as important, we identify those things that might not change. Forewarned, as they say, is forearmed.