Appendix A: The Background of the Integrative Model

Brief Couples Therapy: Group and Individual Couple Treatment for Addiction and Related Mental Health Concerns

The Integrative Model of treatment utilized in the Family Service at the Centre for Addiction and Mental Health (CAMH) incorporates three evidenced-based approaches that have been established as effective with a wide variety of populations and problems: family systems theory and family therapy, solution-focused therapy and cognitive behavioural therapy. Family systems theory is the overarching paradigm that informs the conceptual framework of the Integrative Model, while cognitive behavioural and solution-focused approaches make up most of the core interventions utilized in this model. An overview of each of these approaches follows to highlight the backdrop of the Integrative Model.

Family Systems Theory

Family therapy and family systems theory evolved from diverse avenues of inquiry and practice, including social scientists’ interest in group dynamics of the early 1920s; the child guidance movement of the 1940s and 1950s; the experience of a large number of social workers engaged in front-line work with troubled families during this same period; the development of marriage-counselling centres; and research into the relationship between family dynamics and schizophrenia (Nichols & Schwartz, 1998). Of the latter, the Palo Alto group (Gregory Bateson, Jay Haley, John Weakland) made a significant contribution to family systems theory and family therapy, despite the fact that their perspective on family functioning with relation to mental illness was different from the way that most practitioners would perceive it today. (See Nichols & Schwartz (2001): Chapter 2, “The Evolution of Family Therapy.”) Bateson was interested in cybernetics, anthropology and communications theory, and he brought concepts — such as “report” and “command” functions of a communicated message and the “double bind” message — from these areas into the emerging field of family therapy.

Cybernetics theory played a significant role as a founding principle of family systems theory. In North America, prior to the middle of the 20th century, the family was not seen as a useful or legitimate focus of clinical attention, but rather as a collection of individuals; and it was the individuals themselves whose characteristics were of concern to researchers and clinicians (McCollum & Trepper, 2001). Cybernetics, developed by mathematician Norbert Weiner at MIT (Nichols & Schwartz, 1998), described the workings of self-correcting systems. The core concept in cybernetics is the “feedback loop,” which is the process whereby information is fed back to the system in order to maintain or alter the workings of the system. Negative feedback among the parts of a system reduces deviation in the whole system, while positive feedback amplifies deviation. One example of cybernetic operation is the way that a thermostat controls the amount of heat produced by a furnace by getting feedback from the environment through its heat sensor.

In adapting cybernetics theory to family functioning, Bateson shifted the notion of causality with respect to family problems from linear to circular causality. Instead of viewing family problems as the (linear) result of past events, Bateson described the cause of family problems as part of ongoing, circular feedback loops (McCollum & Trepper, 2001). Bateson and his Palo Alto group infused the notion of the system into family theory, generating a picture of the family system as one in which the whole cannot be understood except through the relationship between its parts. In his view, families include multiple sets of systems, and these systems interact continuously, providing feedback that maintains or alters the system as a whole. When drugs and alcohol are considered from the perspective of a systems approach, the behaviour of the person with the substance use problem affects individual family members in multiple ways and the reactions of family members affect the experiences and the actions of the person who is using drugs or alcohol. This pattern occurs within the family of origin and across extended systems as well.

Family Therapy

Family therapy encompasses several approaches to family functioning and therapy. Included in these approaches to family therapy are the following: intergenerational, structural, strategic, experiential and communications, feminist, social learning, cognitive behavioural and psychoanalytic. What all of the family therapy approaches have in common is the conceptualization of the family as a system, and a focus of clinical attention on the relationships between people to a greater extent than on intrapsychic phenomena and individual behaviour. From within this paradigm, the Integrative Model draws primarily, but not solely, upon principles and techniques from intergenerational, structural and strategic family therapies.

Intergenerational family therapy was conceived by Murray Bowen, who was one of the most influential pioneers of the family therapy movement, and his theory of family functioning was the most comprehensive within the family systems paradigm (Nichols & Schwartz, 1998). Bowen (1978) argued that family members’ problems were related to poor “differentiation of self,” which refers to a person’s ability to separate his or her emotional functioning from his or her intellectual functioning, and he further postulated a “multigenerational transmission process” whereby lower levels of differentiation get transmitted from one generation to the next. Intergenerational family therapy, therefore, focuses on processes among generations. The Family Genogram (or Family Tree) is a technique that is often used to explore these processes.

Structural family therapy grew out of the clinical work of Salvador Minuchin (1974). Minuchin’s perspective on family functioning and therapy was informed by his work with underprivileged families and institutionalized children (Nichols & Schwartz, 1998). Minuchin proposed that problems were the result of dysfunctional structures within the family. Thus, the goals of structural family therapy are to clarify boundaries, subsystems and power hierarchies within the family (as well as the external social forces that impinge upon the family) and to reorganize the family into a more functional structure. These goals are accomplished first by “joining” with the family from a position of acceptance and respectful leadership, and then restructuring the family by utilizing techniques such as “enactment,” in which family members are asked to role-play their relationship patterns, and “reframing,” or changing the labels attached to behaviours from the perspective of understanding the family structure.

Strategic family therapy is a brief, problem-focused therapy that was developed by Jay Haley, who had worked with Salvador Minuchin, and Cloe Madanes, at the Philadelphia Child Guidance Clinic. In 1974, Madanes and Haley opened the Family Therapy Institute in Washington, D.C. (Nichols & Schwartz, 1998). Their brand of family systems theory, which continues to be widely used, sees family interactions as communication patterns. Haley (1976) described the notion of the “behavioural sequence.” Behavioural sequences are the occurrences of problems in families, viewed in terms of regular, predictable patterns of family interactions or events. Haley suggested that if you change a step along the sequence of events, then you will often change the outcome. In order to effect these changes, strategic family therapists make use of a wide variety of creative techniques (Nichols & Schwartz, 1998; McCollum & Trepper, 2001), including “reframing” interventions to alter family members’ perceptions of the problem and “paradoxical interventions,” which utilize client resistance in the service of eliciting positive behaviour change by encouraging its opposite.

As mentioned above, there are a number of other family therapy approaches that are reflected to a lesser extent in the CAMH Integrated Model. Carl Whitaker is the primary proponent of experiential family therapy, a somewhat atheoretical, spontaneous approach to family therapy, while Virginia Satir’s approach, which has also been described as experiential, is known as a communications therapy. Satir used creative techniques such as “family sculpting” (role plays) to help family members become aware of their familial roles and interrelationships (McCollum & Trepper, 2001). Social learning and cognitive behavioural approaches to family therapy focus on the identification of skill deficits, behaviour modification and positive reinforcement strategies, skill-building techniques, and specific behavioural goals, such as problem solving and contingency contracting (Nichols & Schwartz, 1998; McCollum & Trepper, 2001). Many of the pioneers of the family systems approach were trained as psychoanalysts, including Nathan Akerman, Ian Alger, Murray Bowen, Lyman Wynne, Theodore Lidz, Israel Zwerling, Ivan Boszormenyi-Nagy, Carl Whitaker, Don Jackson and Salvador Minuchin (Nichols & Schwartz, 1998). There are a number of different schools of psychoanalytic theory, including object relations theory, self psychology and Freudian theory. Overall, within the psychoanalytic framework, behaviour is the result of intrapsychic factors to a greater extent than external factors, and the goal of therapy is to free family members from the unconscious forces that limit healthy functioning (Nichols & Schwartz, 1998).

Feminist family therapy adds a different perspective to the other approaches by utilizing a feminist framework to deconstruct the gender biases and power hierarchies inherent in the more traditional approaches, and to recognize the realities of women’s experiences. Proponents of the feminist family therapy perspective are Marianne Walters, Betty Carter, Monica McGoldrick, Peggy Papp and Olga Silverstein (McCollum & Trepper, 2001; Nichols & Schwartz, 1998).

Solution-Focused Therapy

Solution-focused therapy grew out of the other family systems approaches, primarily from strategic family therapy. (See Nichols & Schwartz (Chapter 11; 1998) for a detailed discussion of the historical line tracing the development of solution-focused therapy from its roots in strategic family therapy.) The major figures spearheading this approach are Insoo Kim Berg and Steve de Shazer, who were trained as brief therapists following the strategic approach of Jay Haley and Cloe Madanes. The theoretical perspective underlying solution-focused therapy is somewhat sparse, because the focus is on generating solutions to problems rather than considering how these problems arose (Nichols & Schwartz, 1998).

Solution-focused therapy is a brief therapy treatment that is technique-driven and future-oriented. While problems are the source of therapeutic material, building and maintaining solutions to these problems are the focus of therapy. Assessing motivation is an important aspect of solution-focused therapy. A method for assessing motivation is to determine whether or not the client is one of the following: a “customer,” who recognizes that there is a problem and wants help to try and solve it; a “complainant,” who sees that a problem exists and wants the therapist to make someone else solve it; or a “visitor,” who denies that a problem exists and does not want the therapist’s help (Berg & Miller, 1992).

Recently, solution-focused therapists have turned their attention to problem substance use (Berg & Miller, 1992; McCollum & Trepper, 2001; Selekman, 2002). As in solution-focused therapy for other problems and issues, solution-focused therapists working with families of substance users focus on solutions rather than problems; join empathically with family members; negotiate a contract; help clients create measurable goals; help clients develop a vision; track problem-solution sequences; and seek and enlarge successes (McCollum & Trepper, 2001).

Solution-focused therapists maintain a focus on positive elements of client behaviours. Some of the techniques used in this therapy include searching out underlying congruent meanings behind opposing goals and positions; using the Miracle Question to develop a positive vision; scaling; tracking problem and solution sequences; listening for exceptions to the problem and calling attention to them; and complimenting successes.

Cognitive Behavioural Therapy (CBT)

Cognitive behavioural therapy (CBT) is a blend of cognitive therapy and behaviour therapy. Cognitive therapy, pioneered by Aaron Beck (1921-) and Albert Ellis (1929-), asserts that change in behaviours and emotions occurs through change in thinking (cognitions); behaviour therapy is based on principles of operant conditioning (Skinner, 1953) and learning theory (Bandura & Walters, 1963). According to social learning theory, human behaviour is learned, as opposed to being the result of innate drives, and it is governed by eliciting factors. From the tenets of operant conditioning, we know that behaviour is affected by its consequences, that reinforcements affect the rate of target behaviours, and that contingencies define the relationship between a behaviour and its consequences. The addition of the cognitive approach to behaviour theory meant an increasing emphasis on cognitions and the recognition of the need for attitude change to promote and maintain behaviour change. The efficacy and effectiveness of CBT for depression and anxiety has been borne out in an extensive body of research (Antony & Swinson, 1996; Beck, 1976; Dobson, 1989).

Cognitive behavioural therapy tends to be relatively short term. The focus of the therapy is on internal and external behaviours as opposed to explanations for behaviour, and it is problem-oriented (as opposed to insight-oriented or experiential). Therefore symptoms, such as panic attacks, depressive ideation and alcohol or drug use, are the legitimate focus of clinical attention. The goals of therapy include restructuring of faulty thoughts, perceptions and beliefs, and developing positive coping skills in order to foster emotional and behavioural change. CBT interventions include challenging irrational beliefs, psychoeducation, communication and social skills-building exercises, and homework assignments.

Brief Couples Therapy

Acknowledgments

Introduction

References

Appendix A: The Background of the Integrative Model

Appendix A: The Background of the Integrative Model

Family Systems Theory

Family Therapy

Solution-Focused Therapy

Cognitive Behavioural Therapy (CBT)

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