Keywords

A frequent complaint observed in psychology clinics applied to problems observed in childhood and adolescence is that formulated by parents: “there was no school for us to learn how to raise our children” (Kazdin & Rotella, 2008; Latham, 1996). For this reason, it is recommended and desirable that the child therapist conduct orientation sessions for parents and other people who live directly with the child.

This recommendation is derived from the observation that, even making use of intervention and producing changes in the child’s behavioral repertoire in the therapeutic context, generalization of behavior does not always occur in other environments, such as home and school. The recommendation is to allow parents to identify their own behaviors that may sometimes be producing and/or maintaining the problems they complain about. According to Marinotti (2012), parental guidance is an integral part of the clinical process with the child; however, this guidance may not be enough to achieve the desired changes. In these cases, an alternative to be considered, based on the analysis of the data obtained and the therapist’s understanding of the case, is family therapy.

This chapter aims to present family therapy as a resource that can be further explored by behavior analysts and suggests in which context to make use of this model of intervention. Furthermore, it describes some possibilities of therapeutic conduction and lists variables, with the intention that the therapist be sensitive to them, in order to guide the clinical management. We will discuss this theme from the perspective of behavior analysis and contributions of the structural family therapy approach, proposed by the psychiatrist and family therapist Salvador Minuchin. It is worth mentioning that this is not the only model proposed to work with families and that one of the expectations with this text is to stimulate the reader’s interest for contents related to family therapy.

The Family and Family Therapy

The importance of intervening in family relationships lies in the fact that the family is the child’s first social environment. It is in this environment that the child learns the first and most varied behavioral repertoires. It is also in this environment that their first experiences of subjectivity usually begin to appear. Some examples of basic behaviors that will be necessary for other more complex behaviors are imitate; identify and name the stimuli around them; receive and show affection; take care of themselves (both body and things); develop a sense of collectivity; identify hierarchy and social roles; develop social skills and competencies; identify, name, and deal with emotions and sensations (both their own and others); perceive themselves; and experience the self, among others. All these behaviors originate in the social environment surrounding the child. In general, this happens in the family context. It is important, therefore, the way in which family members establish relationships among themselves, because this will influence how each one behaves within the family system and the child’s behavior before the world.

Definitions of what a family would be are usually rare, perhaps because the plurality of possible conformations is very vast, often not finding a common link that can be extracted from the essence of the concept “family.”

Minuchin et al. (2008) provide the following definition for family:

A family is a group of people, connected by emotion and/or blood, who have lived long enough to have developed patterns of interaction and stories that justify and explain those patterns of interaction. In their patterned interactions with each other, family members construct each other. This complementary construction in the family web of transactions is both good news and bad news (p. 52).

This definition seemed quite comprehensive to us and can be considered a starting point to address what kind of relationships should be contemplated in a therapeutic family relationship. In this way, we are not referring to a specific model of formation of the family structure but to the social function of the existing relations between the members of a particular group, which is conventionally called family.

Another important aspect for the development of therapeutic work is to take into account the formulation of the analysis of behavior on the development of the repertoire of each individual inserted in social relationships – in this case, in family relationships. As in other interactions with the environment, the behavior of the participant in the family group is motivated by his biological needs for survival – and later, for reproduction – and modeled by his consequences, strengthening or weakening classes of responses. Thus, the family group can determine the variability or restriction of the behavioral repertoire of its members. For this reason, describing, organizing, and intervening in the relationships established among the group members may indicate changes that provide a harmonious and healthy scenario.

It is expected that families experience some situations such as the formation of a new couple; the conception of a baby; the presence of a small child; the entry of children at school age, adolescence, or adulthood; the illness of a member; the death of one of the members; the loss of a job; retirement; the breakup of a marital relationship; the adoption of a child; and the union of partners with children, among others. These experiences are an opportunity to develop new repertoires, but alter previously established relationships, occurring gains and losses for each individual. Because of this, there is a process of adaptation to the new reality, which, depending on the developments, may expand healthy behaviors or show sick relationships.

It is through the process of family therapy that the psychologist can observe and act when events are occurring, when the individual repertoires of members of the family group do not reach the necessary adaptation, without creating an aversive social environment. Another particularity of this model of assistance is the opportunity to change the focus of the problem which is normally attributed to a single individual and to start working with the general functioning of the family, emphasizing the relationships established between its members. To this end, the behavior analyst should pay attention to how the tasks characteristically assigned to the mother, father, husband, wife, child, and sibling, among others, are performed and how relationships are established between these performances.

The theoretical foundation seeks to understand how relationships between family group members are established and the possible interlocking contingencies (Glenn, 1986), in which, as described by Naves and Vasconcelos (2008), the behavior of an individual becomes an occasion or consequence for the behavior of another individual from the same social group. This conception originated in Skinner’s (1953/1985) proposition on social behavior, which defines it as a behavior that takes place in the relationship of one person with another or of two or more people in joint relation with the physical environment. One of the advantages of this type of behavior is that all those involved in the social relationship produce a result that would not be produced if the individual contingencies were not interlocking in that way.

A consequence of this proposition is that when we observe a relationship in which someone obtains advantages and another loses them, we will be identifying a bad social relationship, which tends to disintegrate, for example, a man who wants to buy a new car for himself and makes the family save, claiming lack of financial resources is the only one to obtain advantage. This is the keynote of family therapy: identify common goals, in which everyone remains satisfied by being together and locate in which types of relationships this “value” is not happening.

Guidelines for the Therapist

The following are suggestions to the work of the family therapist. Probably some of them will be obvious to some readers, but it is worth remembering them. The physical environment of the therapy should have enough space to accommodate the family comfortably, considering the number of seats, lighting, and air circulation. It is interesting for the therapist to have accessible tissue, water, graphic materials, toys, and games, and it is important, in some cases, to have enough space so that people cannot reach each other when accommodated.

The therapist can determine the length of the session, but the literature recommends that in group therapy, having or not a family configuration, the sessions last between 90 and 120 min. The presence of a therapist is indicated in family groups with more than three members, and the supervision of beginning therapists is fundamental.

The therapist needs to consider that his life and professional experiences, personal values, and theoretical knowledge create a bias in his analysis, which may bias his judgment toward family members who live similar contingencies to his own (Banaco, 2008). For example, a therapist who is a father and contributes significantly to his own household finances may empathize more easily with the complaints of a mother who is the breadwinner. On the other hand, a therapist who has much of his or her needs met by funding from other family members may more easily understand the entitlement claims of a child who is being supported by siblings.

Thus, it is important that both a therapist who attends a family alone and the co-therapists who attend together are always willing to revise their interpretations about the family dynamics. The therapist’s self-knowledge and self-observation are required to facilitate the identification of the effects that the speeches and actions of the members of the family group have on him/herself. Furthermore, they help him to identify if, when allying himself to one of the members or to a family subsystem, his conduct is guided by a clinical rationale or if he is allying himself to this person for sharing or even for disagreeing with the values that are being imposed to whom he has allied himself.

Descriptions of what is observed by the behavior analyst should be free of prior moral judgments. They should also show the antecedents and consequences produced by certain responses. The purpose of this procedure is to help family members improve their repertoire of identifying and expressing emotions and thoughts, resolving conflicts, making requests, and identifying the variables that control their responses.

In the sessions, the therapist should ideally focus on the interactions among family members rather than on the interaction with each member. In this way, he can witness how the members relate to each other and help improve interpersonal skills. Another therapeutic task is to identify the target behaviors when they occur in the session so that they can be consequenced as close as possible to their emission. For example, during a family session situation report, the daughter will tell the parents directly how she feels (instead of telling the therapist in front of the parents). Thus, she will emit in therapeutic session the class of responses that is intended to be carried out of the session. At that point, notation of the change that has occurred can be made by the psychologist, which can have a reinforcing effect on this interlocking.

The content of the verbal discourse is adjacent and assists in understanding the case. It is the observation of the interactions between the members of the family group that will be most important. The therapist must be attentive to how the report occurs, the context in which it is presented, the emotional expression of the speaker and listeners, the interactions originated from what was said, and the identification of what is being said beyond the words – for example, with autoclips such as voice intonation, speed, metaphors used, etc., which significantly extend the understanding of the family functioning. This observation helps the therapist to define the therapeutic objectives and identify the interventions to be performed.

It is essential to adapt the interventions and the way of interacting according to the family members, respecting their moral, ethical, and religious values. With children, it is appropriate to stoop down when interacting with them; be succinct, clear, and specific in the verbal account; use playful resources; and carry out interventions with the concrete use of language. Intervention techniques should be subordinate – never sovereign – to the formulation and reformulation of the case and the contingencies present in the session. Therefore, therapists should have in their repertoires the domain of quite diversified techniques for the most different purposes.

In addition, very specific issues concerning the couple’s relationship (e.g., sexual life or the intimacy of one of the members of the couple) should be addressed separately from the children’s problems, just as, depending on the age and education of the children, issues of their intimacy should be addressed separately from those of their parents. For the family session, issues that affect everyone’s contingencies should be reserved.

And, finally, it is recommended to observe, encourage, and allow family members to seek alternatives to deal with a problematic situation, always having in mind, as a guiding sense, the objective of the group. On the other hand, the behavior of the psychologist to list several solutions for a situation may be considered a conduct of little therapeutic effect, because they sound like recommendations. Rodrigues et al. (2014) cite studies by authors from different psychological approaches who found evidence that the therapist’s directivity is a determinant of the client’s resistance and understand it as an interactional phenomenon, i.e., it may occur according to the style of the therapist’s interventions.

Suggestions for Conducting the Process

Based on the data obtained in the initial sessions, the therapist will perform the case formulation that is composed of (a) the identification of the current variables and those related to the history of the family or individuals that maintain the problem behavior, (b) the identification and definition of the classes of behaviors that should be reduced and those that should be expanded, (c) the survey of the interventions that will possibly be used for each of the purposes, (d) the composition of the therapeutic goals defined with the family, and (d) the constant re-evaluation of the psychotherapeutic process with the subsequent reformulation of the clinical case, given that behavior is a process in constant development; or, in other words, the formulation of the case is fluid and needs to be revised during therapy as new data are obtained; otherwise, there is the risk of the professional becoming insensitive to new contingencies that life or the therapy itself have modified.

In order to verify how the family members interact, it is advisable to conduct some sessions without making explicit which behaviors are expected from the participants when expressing their emotions, complaints, and point of view. After defining the objectives and target behaviors of each family member – and of the dyad or triad of therapists – they can be asked to express themselves verbally, attending to certain recommendations (e.g., expressing without judgment, aggressions, ironies, and threats) in order to model some behaviors of affect expression in session.

Minuchin et al. (2008) propose a four-step map to assist the therapist in formulating the case and promoting knowledge of family relationships for its members. Table 14.1 presents the original version and a proposed adaptation to the analytic-behavioral terminology.

Table 14.1 Adaptation of Minuchin, Lee, and Simon’s (2008) four-step map summary
Full size table

During the psychotherapeutic process, the therapist will have the opportunity to identify the classes of responses related to the parental, conjugal, fraternal, filial, and individuality repertoires. The objective is to understand how they are exercised and interact among themselves, verifying if there are conflicts between the roles played, alliances, or subgroups, helping the members of the family group to perceive themselves as a whole, establishing the responsibility of each one, given that each one is context for the response of the other.

The behavior analyst has at his disposal a theoretical and technological framework that supports his practice and, when used, contributes to the well-being of individuals living in groups. The professional can make use of this technology when the work is directed at the family. Some general possibilities of interventions are presented below.

The functional hypothesis established in the formulation of the case is the instrument used by the behavior analyst to diagnose and assess the therapeutic process, being the starting point for the planning and monitoring of interventions (Nery & Fonseca, 2018). If well used, it can also be an instrument that contributes to self-knowledge, to the expansion of the repertoire, and to the occurrence of changes in the repertoires of each participant in family therapy.

The therapist(s) can prepare the family for the use of contingency analysis, helping everyone to make the observation of chained events in which each one of them (the family members) has a participation in the problematic episode. This can be done, initially, through examples extracted from the verbal report of the family members, but preferably should be pointed out in the events that occur in session. Later, with the elaboration of functional analyses through the participation of family members in small behavioral changes, the therapist helps the members of the family group to observe and have control over their interactions.

To increase the likelihood of success in interventions, it is recommended that the therapist(s) share the knowledge produced by behavioral psychology with the family. Latham (1996) lists the following principles: (a) behavior is better modeled by positive consequences than by negative consequences; (b) one can only know whether behavior was punished or reinforced by the course of behavior in the future; (c) behavior is largely a product of the immediate environment; and (d) behavior is modeled by consequences. Guided by these principles, the therapist may present the concepts of reinforcement and punishment, extinction, contiguity and contingency, reinforcement schemes, modeling, shaping, establishing operations, arbitrary and natural reinforcers, and aversive control, among others. It is recommended that professionals, when transmitting these concepts, whenever possible, use information obtained through the report of the members of the family group and the events observed during the session.

The principles of behavior analysis that are taught to the family will of course be used by the therapist in session for interventions. For example, as proposed by Delitti and Derdyk (2012), modeling and instruction can be used by the clinician in a planned manner to teach a specific repertoire during the therapy session. Delitti and Derdyk report that: “From behavioral modeling and rehearsals, it is possible to install or change many behaviors, from the behavior of observing oneself and others, analyzing and describing contingencies, social skills, empathy, communication, self-disclosure, coping, etc.” (Delitti & Derdyk, 2012, p. 265). The authors emphasize that, for the modeling strategy to be effective, it is necessary to describe the problem situation, decompose the behavioral sequence, give instructions or performance model, rehearse, hint about the performance, program generalization, and assess the performance in the natural situation.

The therapist, when reporting his sensations, emotions, and thoughts as a result of a situation observed in session, can also serve as a model for the family members of how to express verbally their limits and inconveniences in an adequate manner. Depending on the circumstance, by making public the effect that the family members’ responses have on him, it is possible to use this data to help model better responses and the perception of their effect on the listener.

Another procedure that aids the installation and strengthening of certain client responses is modeling: the precursor responses of the desirable response are initially reinforced, and as they are established, reinforcement gradually moves to new responses hierarchically closer to the target response (Del Prette & García, 2007, p.185).

A basic recommendation that should start the whole therapeutic process is the use of positive reinforcement rather than coercive control because it produces the strengthening of affective interactions and improves life values and the behavioral repertoire of the people involved. Emphasizing the bond between parents and children, as stated by Sidman (1989/2009), is a way to help children to have a productive and happy life, without feeling they need to do something special to get love and protection. In addition, it is to provide an environment in which they feel safe and that, even if they do something wrong, they still know they will have protection and affection.

As mentioned elsewhere in this text, the therapist must privilege interventions related to the events that occur in session. Yalom and Leszcz (2006) understands that for this to occur, the therapist needs to help the group to get involved in the here-and-now experience and help them to understand the process of the experience, that is, to get in touch with the contingencies present in the interaction. The ability to focus on the present moment allows the members of the family group to identify more easily the triggers of their good and bad behaviors, as well as their tendencies to respond to the issues of the family relationship. They can then make more conscious choices about how to act.

In order to achieve these objectives, it is necessary to be aware of what is happening in the present moment; observe and, when appropriate, describe the internal and external events in face of the situations experienced in session by the family members and therapists; and identify and consequentize the clinically relevant behaviors, which are already described in the case formulation. Therapists who adhere to the therapeutic process known as FAP (functional analytic psychotherapy) describe these behaviors as clinically relevant behaviors (clinical relevant behaviors – CRBs). In these processes, therapists should recognize functional parallels between behaviors presented in session and those that occur in clients’ lives outside the office, enhance behaviors of vulnerability, and use the therapeutic relationship as a model of interaction for family members. Hoekstra and Tsai (2010) state that FAP provides a theoretical framework and format for behavior analysts who work with groups and focus on improving interpersonal relationships.

It is also possible to use therapeutic resources described by ACT (acceptance and commitment therapy) to help the family identify and behave toward their values. Brandão (2008) understands that elucidating the clients’ values and commitments to act according to the established goals is a didactic way to start the sessions. Having a family’s values clear helps therapists to define broad classes of target responses to which they can direct the behavioral repertoires to be installed in each family member. The model proposed by ACT can help the therapist, through relational frame theory (RFT), to understand and reveal the frames established in the family relationship. In other words, succinctly, it reveals how excessive verbal control and arbitrarily established relationships may influence the maintenance of a limited repertoire that is not very flexible and insensitive to reinforcing contingencies.

It is worth emphasizing that what has been discussed so far will only make sense if professionals and members of the family group, when evaluating the results obtained, notice changes that promote improvement in family interactions beyond the clinic. Therefore, the planning of generalization of the behaviors worked on in the clinical context must be considered by the therapist whenever he elaborates his intervention plan.

Final Considerations

This chapter was aimed at identifying some situations that can produce changes in family relationships, which in turn can considerably affect the behavior of children. Parental guidance skills are sufficient to conduct several therapeutic processes for children, but sometimes the origin of the problems faced and experienced by children is found in the family relationships themselves. It is up to the therapist to identify if and when guidance will be sufficient and when a more robust therapeutic process should be conducted to solve the problems brought to the clinic.

Changes in structural living conditions – such as the entrance and/or exit of someone in the family life – usually produce great influence on the child’s social relations, demanding that the adaptation process be conducted in a safe and coherent way. The process should be conducted so that everyone in the family can benefit from the changes pursued by the indications of the behavioral formulation. The therapist must consider the behavior of each family member as the social context in which the behavior of the other family component occurs, distributing to all the problem and the weight of the intervention and of the change. The family becomes “having a problem” and not just “having a child who was considered problematic.”

The proposals of adaptation described by Minuchin et al. (2008) in analytic-behavioral terms were presented, so as to be followed by the therapist as a set of rules. They are guidelines for a good family service, and the reader can find in the literature cited below other works that are of aid to the conduction of a complex process, such as the therapy of the “family” group. Because it is complex, the work in co-therapy is indicated, and the supervision of the case receives special attention, so that the therapist(s) do not incur in common and probable mistakes, specially empathizing with one or part of the family members.

The great advantage of therapy conducted this way is that the processes to be worked on will be manifested under the eye and technique of the therapist(s). In short, parents can have a school to learn how to develop their children’s behaviors.