Family therapy is a process, method, and technique of psychotherapy in which the focus is not on an individual but on the total family as an interactional system (see also Major Theoretical Models, Summary of Theories of Psychosocial Development Throughout the Life Cycle).

1. DEVELOPMENTAL TASKS OF NORTH AMERICAN FAMILY (Duvall, 1971):
1. Physical maintenance—provide food, shelter, clothing, health care.
2. Resource allocation (physical and emotional)—allocate material goods, space, and facilities; give affection, respect, and authority.
3. Division of labor—decide who earns money, manages household, cares for family.
4. Socialization—guidelines to control food intake, elimination, sleep, sexual drives, and aggression.
5. Reproduction, recruitment, release of family member—give birth to, or adopt, children; rear children; incorporate in-laws, friends, etc.
6. Maintenance of order—ensure conformity to norms.
7. Placement of members in larger society—interaction in school, community, etc.
8. Maintenance of motivation and morale—reward achievements, develop philosophy for living; create rituals and celebrations to develop family loyalty. Show acceptance, encouragement, affection; meet crises of individuals and family.
2. BASIC THEORETICAL CONCEPTS RELATED TO FAMILY THERAPY:
1. The ill family member (called the identified client), by symptoms, sends a message about the "illness" of the family as a unit.
2. Family homeostasis is the means by which families attempt to maintain the status quo.
3. Scapegoatingis found in families who are disturbed and is usually focused on one family member at a time, with the intent to keep the family in line.
4. Communication and behavior by some family members bring out communication and behavior in other family members.
1. Mental illness in the identified client is almost always accompanied by emotional illness and disturbance in other family members.
2. Changes occurring in one member will produce changes in another; that is, if the identified client improves, another identified client may emerge, or family may try to place original person back into the role of the identified client.
5. Human communication is a key to emotional stability and instability—to normal and abnormal health. Conjoint family therapy is a communication-centered approach that looks at interactions between family members.
6. Double bindis a "damned if you do, damned if you don't" situation; it results in helplessness, insecurity; anxiety; fear, frustration, and rage.
7. Symbiotic tieusually occurs between one parent and a child, hampering individual ego development and fostering strong dependence and identification with the parent (usually the mother).
8. Three basic premises of communication^*:
1. One cannot not communicate; that is, silence is a form of communication.
2. Communication is a multilevel phenomenon.
3. The message sent is not necessarily the same message that is received.
9. Indications for family therapy:
1. Marital conflicts.
2. Severe sibling conflicts.
3. Cross-generational conflicts.
4. Difficulties related to a transitional stage of family life cycle (e.g., retirement, new infant, death).
5. Dysfunctional family patterns: mother who is overprotective and father who is distant, with child who is timid or destructive, teenager who is acting out; overfunctioning "superwife" or "superhusband" and the spouse who is underfunctioning, passive, dependent, and compliant; child with poor peer relationships or academic difficulties.
3. FAMILY ASSESSMENT should consider the following factors:
1. Family assessment: cultural profile (see also Chapter 3. Safe, Effective Care Environment)^†:
1. Communication style:
1. Language and dialect preference (understand concept, meaning of pain, fever, nausea).
2. Nonverbal behaviors (meaning of bowing, touching, speaking softly, smiling).
3. Social customs (acting agreeable or pleasant to avoid the unpleasant, embarrassing).
2. Orientation:
1. Ethnic identity and adherence to traditional habits and values.
2. Acculturation: extent.
3. Value orientations:
1. Human nature: evil, good, both.
2. Relationship between humans and nature: subjugated, harmony, mastery.
3. Time: past, present, future.
4. Purpose of life: being, becoming, doing.
5. Relationship to one another: lineal, collateral, individualistic.
3. Nutrition:
1. Symbolism of food.
2. Preferences, taboos.
4. Family relationships:
1. Role and position of women, men, aged, boys, girls.
2. Decision-making styles/areas: finances, child rearing, health care.
3. Family: nuclear, extended, or tribal.
4. Matriarchal or patriarchal.
5. Lifestyle, living arrangements (crowded; urban/rural; ethnic neighborhood or mixed).
5. Health beliefs:
1. Alternative health care: self-care, folk medicine; cultural healer: herbalist, medicine man, curandero.
2. Health crisis and illness beliefs concerning causation: germ theory, maladaptation, stress, evil spirits, yin/yang imbalance, envy and hate.
3. Response to pain, hospitalization: stoic endurance, loud cries, quiet withdrawal.
4. Disease predisposition:
1. African Americans: sickle cell anemia; cardiovascular disease, brain attack (stroke), hypertension; high infant mortality rate; diabetes.
2. Asians: lactose intolerance, myopia.
3. Latinos: cardiovascular, diabetes, cancer, obesity, substance abuse, TB, AIDS, suicide, homicide.
4. Native Americans: high infant and maternal mortality rates, cirrhosis, fetal alcohol abnormalities, pancreatitis, malnutrition, TB, alcoholism.
5. Jews: Tay-Sachs disease.
2. Family as a social system:
1. Family as responsive and contributing unit within network of other social units.
1. Family boundaries—permeability or rigidity.
2. Nature of input from other social units.
3. Extent to which family fits into cultural mold and expectations of larger system.
4. Degree to which family is considered deviant.
2. Roles of family members:
1. Formal roles and role performance (father, child, etc.).
2. Informal roles and role performance (scapegoat, controller, follower, decision maker).
3. Degree of family agreement on assignment of roles and their performance.
4. Interrelationship of various roles—degree of "fit" within total family.
3. Family rules:
1. Family rules that foster stability and maintenance.
2. Family rules that foster maladaptation.
3. Conformity of rules to family's lifestyle.
4. How rules are modified; respect for difference.
4. Communication network:
1. How family communicates and provides information to members.
2. Channels of communication—who speaks to whom.
3. Quality of messages—clarity or ambiguity.
3. Developmental stage of family:
1. Chronological stage of family.
2. Problems and adaptations of transition.
3. Shifts in role responsibility over time.
4. Ways and means of solving problems at earlier stages.
4. Subsystems operating within family:
1. Function of family alliances in family stability.
2. Conflict or support of other family subsystems and family as a whole.
5. Physical and emotional needs:
1. Level at which family meets essential physical needs.
2. Level at which family meets social and emotional needs.
3. Resources within family to meet physical and emotional needs.
4. Disparities between individual needs and family's willingness or ability to meet them.
6. Goals, values, and aspirations:
1. Extent to which family members' goals and values are articulated and understood by all members.
2. Extent to which family values reflect resignation or compromise.
3. Extent to which family will permit pursuit of individual goals and values.
7. Socioeconomic factors (see list in (Table 10.9. Individual Assessment), Psychosocial Integrity).
4. NURSING CARE PLAN/IMPLEMENTATION in family therapy:
1. Establish a family contract (who attends, when, duration of sessions, length of therapy, fee, and other expectations).
2. Encourage family members to identify and clarify own goals.
3. Set ground rules:
1. Focus is on the family as a whole unit, not on the identified client.
2. No scapegoating or punishment of members who "reveal all" should be allowed.
3. Therapists should not align themselves with issues or individual family members.
4. Use self to empathetically respond to family's problems; share own emotions openly and directly; function as a role model of interaction.
5. Point out and encourage the family to clarify unclear, inefficient, and ambiguous family communication patterns.
6. Identify family strengths.
7. Listen for repetitive interpersonal themes, patterns, and attitudes.
8. Attempt to reduce guilt and blame (important to neutralize the scapegoat phenomenon).
9. Present possibility of alternative roles and rules in family interaction styles.
10. Health teaching: teach clear communication to all family members.
5. EVALUATION/OUTCOME CRITERIA: each person clearly speaks for self; asks for and receives feedback; communication patterns are clarified; family problems are delineated; members more aware of each other's needs.

^* Adapted from Watzlawick, P: An Anthology of Human Communication. Science and Behavior Books, Palo Alto, CA. (out of print)

^† Adapted from the classic work by Fong, C: Ethnicity and nursing practice. Topics Clin Nurs 7(3):4, with permission of Aspen Publishers, Inc. © 1985.