What is family therapy? There are many different models of treatment for families in distress, and it is beyond the scope. In most models of family therapy, all the members of a nuclear family are seen in a group session with one or two therapists or counselors. In some models, only one or two members may be seen, and the treatment is considered to be family therapy because the focus of discussion is on family relationships. At times, members of the extended family may also be involved in treatment, especially if they are closely concerned with the problems, as is often the case in families where there is neurological impairment of one of the older members. Treatment sessions are typically held weekly for ninety minutes, although they may be spaced more widely apart. In one model, families are brought in for an initial two-day treatment session and then brought back several weeks or months later to follow up on the treatment and to make further interventions if necessary. This is a useful model for families where members are spread over a wide geographical area.In most models, family relationships are treated, rather than anyone individual in the family, although frequently one person is the identified patient. In the family with a neurologically impaired member, the other members may define the demented individual as the patient or they may define one of the other family members as the dissatisfied one, i.e., the problem for everyone else. On the other hand, the family may come into treatment all acknowledging their distress, and ask for coping skills. In the early stages of treating families with a neurologically impaired member, the interventions may involve education about expectations of the impaired person, prognosis, and coping skills. However, treatment may need to go beyond education in order to maximize the well-being of both the family and the demented patient.

According to one model of family therapy, inappropriate behavior patterns are the result of family members oversensitivity to and compliance with one another’s needs and wishes to the detriment of their own development as individuals. Therapy sessions seek to demonstrate such entanglements. For example, some grown children may cope with a demented mother by avoiding her, while one daughter may respond to her brothers and sisters un involvement by becoming totally involved in caring for the mother, even to the point of neglecting her own nuclear family (i.e., her husband and children). She may resent her siblings’ lack of involvement at the same time that they feel guilty about abandoning their sister and their mother. Or, more subtly, the caregiver may shield the other family members from discovering the extent of their relatives impairment, protecting them from a fact that they do not want to face. As a result, the caregiver prohibits herself from confiding in others about her feelings or asking for relief from her duties, and/or the rest of the family criticizes her when she does complain because they believe there is so little to complain about.

Family treatment would consist of demonstrating such patterns of protection, thereby helping family members to perceive their own feelings and roles in creating and maintaining such patterns. Therapy consists of helping family members to gain insight into maladaptive entanglements and to develop new, more adaptive patterns. In another treatment model, families are viewed as having problems because they do not communicate straightforwardly, often using complicated communication patterns to maintain control over other family members. For example, one rather uninvolved member of a family may criticize the caregiver for discussing the possibility of putting the impaired member into a nursing home, the implication being that the caregiver does not love the patient. This may be an effort to handle personal guilt about abandoning the family member by attempting to keep the patient in the caregiver’s home. Therapists may attempt to change levels of communication to more straightforward patterns by showing the family how to communicate well. Then again, therapists may engineer changes in one person’s behavior that will automatically change the whole family’s way of communicating.

Yet a third treatment model examines the family members’ ways of communicating rather than what they communicate to each other. For example, members of the family may communicate only with each other, rather than with nonmembers, as in the case of a family that will not allow its members to let outsiders know about its problems, even when there is a desperate need for expert help. Yet the family itself may not ever resolve the problem, so that one or more of the members eventually feels great distress. Such a family would be said to be too enmeshed or intertwined with one another and too separated from the rest of the world. Certain particularly troubled families have been found to avoid seeking outside help with problems revolving around caring for an Alzheimer patient.

Therapy within such a framework involves helping the family to restructure itself to deal more effectively with the current situation, bringing in outside help if necessary. If the family is not enmeshed, but disengaged (that is, not sensitive enough to each other’s communications), members may need help to restructure their relationships to be closer. Typically the therapist helps the family to change by engaging in exercises that give them practice in seeing current ways of communicating and in using new patterns of communication. For instance, the barriers between two subsystems may be too rigid for messages to pass across, so the therapist may ask one of the members to sit next to another member and to address him or her directly.

Studies have not uniformly shown family counseling to be successful in alleviating problems associated with caring for Alzheimer patients. For instance, family counseling focused on problem solving has sometimes yielded poor results. However, at least one study reported the success of family counseling in which the caregivers were taught to communicate their needs and the family to listen sensitively and to give emotional as well as practical support.

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