Assimilative Family Therapy
Name of the Strategy or Intervention
Assimilative Family Therapy Model
Pitta integrated Bowen Family Systems Therapy with cognitive behavioral, psychodynamic, communications, and other systems therapies into Integrative Healing Family Therapy (Pitta 2005). As her thinking evolved, she began to consider context (Brabender and Fallon 2009) and common factors (Davis et al. 2012). She then labeled this therapy for individuals, couples, and families the Assimilative Family Therapy (AFT) model (Pitta 2014). The home theory of AFT is a systemic theory or family therapy model, and the concepts and interventions from other therapies can be from individually oriented treatment therapies and other family therapy models.
Theoretical Framework for the AFT Model
Four major models have been identified within the field of integration: technical, theoretical, common factors, and assimilative integration (Norcross and Goldfried 2005). Technical integration uses a systemic reasoning process and integrates techniques from different approaches to meet the needs of the client to attain growth and change. Theoretical integration looks at how different models can be integrated to form a model of treatment that is more powerful than either model separately. Common factors look at how effective treatments result in positive change processes that are not specific to any theory or model, while also measuring the alliance between client(s) and therapist. These factors include: the client viewing the therapist as someone who can help; the client(s) being committed and motivated to do the work of therapy; having hope that their realistic expectations can be reached (Davis et al. 2012). Finally, Assimilative Integration names a home theory as the main theory and then integrates concepts and interventions from other theories to support the goals of the home theory and the goals set out by therapist and clients for the course of their treatment (Messer 2015).
Bowen Family Systems Therapy is a theoretical framework that looks at generational patterns, including transmission processes, that addresses why a client may be acting in a certain way. Often, they are repeating the patterns of previous generations. It also looks at triangulation within a system and addresses how a person can get stuck within the family processes and not be able to further differentiate. This therapy also defines concepts such as cutoffs, intergenerational transmission processes, triangulation, fusion, differentiation, pursuit-distance patterns, coaching, and how these concepts defines and help change thoughts, behaviors, and feelings of individuals and family functioning. In addition to identifying dysfunction, this framework also looks for health in the system to promote changes. The major goals of Bowen Family Systems work are to lower anxiety and emotional reactivity and increase differentiation (Bowen 1976).
Pitta added concepts and interventions from Cognitive Behavioral Therapy, including cognitive relabeling, assertiveness training, relaxation therapy, role-play and modeling, behavioral parent training, contingency contracts, reinforcement, punishment, and mindfulness to integrate with the home theory. Additionally, AFT examines psychodynamic defenses such as repetition compulsion, denial, doing and undoing, repression, distortion, splitting, and projection and projective identification are also integrated. Gottman’s Sound House Theory is utilized within this model (Gottman 1999). Lastly, other systemic theories, concepts, and interventions such as re-parenting parents, drawing boundaries, and exposing family secrets are also integrated with the home theory.
Included in the AFT model (Pitta 2014) is a deep respect for context (age, ethnicity, culture and racial backgrounds, sexual identity and relationship status, socioeconomic status, life stage, life cycle, resilience, attachment, emotional regulation, optimism, chronic illness, religion, spiritual affiliation, and spiritual beliefs). Levels of resistance are determined through the use of a resistance questionnaire (Pitta 2014, p. 293).
Building on a genogram (McGoldrick et al. 2008) assembled in the initial sessions, the therapist is able to formulate a case conceptualization that holds an important key to help clients and therapist to form their goals of treatment. In Solving Modern Family Dilemmas: An Assimilative Family Therapy Model (Pitta 2014), a case conceptualization questionnaire (p. 295) is presented that enables therapists to create their own conceptualizations about the cases they are treating. Assimilative models, and the AFT model in particular, are generic models; therapists can create their own AFT model by identifying their systemic model as a home theory and then integrating concepts and interventions from other theories.
Populations in Focus
The AFT model can be applied to couples, families, and individuals, because it uses Bowen Family Systems Therapy, a systemic theory, as the home theory. This theory has been applied to all populations throughout the life cycle. Its main goals of lowering anxiety, regulating emotions, and helping individuals differentiate can apply to all systems.
Strategies Used in the Model
The process for the model is as follows: Before beginning treatment, each family member fills out a contextual questionnaire to offer the treating therapist essential information about their specific contexts. From this, the therapist draws a contextual diagram that indicates the contexts that this family lives within. This offers the therapist a photo of who the family members are in relation to their ages, culture, ethnicity, and racial backgrounds, sexual identity, marital status, life stage and life cycle, socioeconomic status, levels of resilience, attachment and emotional regulation, optimism, chronic illnesses, religion, spiritual affiliation, and spiritual beliefs. Second, the therapist has the clients fill out a resistance questionnaire that the author created (Pitta 2014) based on the work of Beutler and Harwood (2002). Through the resistance questionnaire, the therapist can determine if clients are demonstrating low or high levels of resistance. Those with low levels can be approached by the therapist in a more direct manner while those who presented as more resistant, the therapist will need to approach in a less directive manner and using questions rather than statements as a means to ascertain information. Third, the therapist meets with the individual, couple, and/or family and ascertains why they are seeking treatment. Fourth, the therapist builds an alliance while meeting with members of family to build a strong bond and provide a safe environment to promote growth and change. Fifth, as the therapist meets with the family, she is constructing a genogram to learn further about the patterns of functioning within and between the generations that might be contributing the presenting dilemmas. As the therapist conducts the first few sessions, she is getting the necessary information to create a case conceptualization with the help of the family, where goals are identified and therapist presents ways to solve presenting dilemmas. This gives the family members a sense of control and understanding about the process of treatment and offers them an active role in creating their therapy to help them resolve issues. The major goals of the home theory are always kept in mind when setting goals and creating a treatment plan. Treatment plans can change as clients make changes in contexts, goals, and extra-therapeutic influences. Important to note is that therapist takes temperature checks (Pitta 2014) during sessions asking clients such questions as: Do they feel comfortable with therapist; do they feel their goals for the session are being addressed; Is there anything else that needs to be addressed before the session ends that helps with ensuring the development and maintenance of the alliance between clients and therapist.
Research About the Model
Integrative approaches have found to be effective when looking at them through a common factor lens, which consider therapy to be most effective when clients feel comfortable and allied with the therapist, and thus also hopeful that positive change can take place (Davis et al. 2012). Further, research shows that any one method of treatment is far surpassed by using the lens of common factors with an integrative perspective (Wampold and Imel 2015). AFT integrates cognitive behavioral, psychodynamic concepts, and interventions and communications interventions derived from their respective theories. These approaches have been shown to be effective treatments through a number of primary and meta-analytic studies (Babcock et al. 2013; Butler et al. 2006; Shedler 2010). AFT is a model that clearly delineates steps that the therapist adheres to, promoting more effective treatments (Datchi and Sexton 2016).
A mother, father, and their teenage daughter presented in therapy because the daughter was being very oppositional at home, despite being an A-student with a flourishing social life. She was particularly disrespectful towards her mother and very demanding of her father for attention and material things. After noticing how both the father and daughter expressed resistance towards therapy, the therapist began focusing not only on the issues with the daughter but in what might be causing those issues from a larger systemic perspective. The therapist discovered the parents’ marriage was fraught with tension because they were repeating the patterns they had witnessed in their own parents’ relationships. The couple’s issues stemmed from around the time they had begun having children. When the wife began dividing her attention among the children and her husband, the husband began to grow angry and distant. To further complicate matters, the wife had become obese as a result of using food as an outlet for her marital anxiety, while her husband smoked cigarettes and pot as a means of coping.
The therapist created a case conceptualization to aid in formulating her treatment plan for this case (Pitta 2014). It appeared that disappointment, rage, and anger described the relationship that the husband and wife had created with each other. Family patterns that were learned in their families of origin were repeated in their relationship as a couple and in their nuclear family. Their daughter had learned their patterns and introjected aspects of their personalities and patterns and acted it out within her personal life and within the nuclear family. If the couple would agree to work on changing their thoughts, feelings and behaviors towards each other, it was possible that their daughter would see the change and more than likely, also change. They needed to work on understanding their mutual responsibility for the dysfunction as well as to appreciate what was functional in themselves and their relationship. They needed to: (1) build new behaviors and interactions that could overcome the negative interactions of the past, (2) work on their communication so they could learn to demonstrate how they appreciated each other and express their own feelings, (3) differentiate themselves from the patterns of their families of origin to become a true self by identifying their “I” positions on matters within themselves and between themselves, (4) remove their daughter from the triangle that was created to keep their marriage together and to allow her to differentiate her position as a daughter to both parents and as an individual, and (5) lower their mutual and individual levels of anxiety and mutual reactivity so the couple could learn how to interact in a more effective, gentler manner. The couple met with the therapist for a total of 18 sessions.
During the third session, the therapist offered the family her conceptualization of how she envisioned the dilemmas they presented and then thanked the daughter for acting out sufficiently to get the parents to look at their relationship. The teen did not want to be in therapy as she clearly stated in the sessions. She said, “I don’t want you to change the way my family functions. I like it just the way it is”. In the middle of the third session, the therapist joined the teen and said that the therapist would work with the parents and she was free for the time being to not be part of the sessions and asked the teen to please wait in the waiting room. The teen was stunned and left the room. This was the first attempt on the part of the treatment to create a boundary that focused on the couple’s functioning and to put power back to parents. The therapist identified for the parents that they allowed the teen to run the family since their behaviors were so conflictual and non-connected and they did not take charge of the family functioning We explored how on some unconscious level the teen was trying to make order in her life, but her adjustments in the home were not functional, but due to her inner strengths, she excelled in school and with friends.
The therapist worked with the couple on their anger revolving around their sense of mutual abandonment of each other upon the birth of their child. They worked on learning to express their feelings that they fought about and distanced from. We worked on each taking responsibility for their behaviors and feelings. They also were encouraged to identify the dream behind their selfish and childlike behaviors. They then were enabled to mourn and grieve the loss of their childlike fantasies.
We also explored how their behaviors were a repetition of their same sex parent in their family of origin and how each needed to differentiate to become their own person. The therapist utilized mindfulness techniques to enable them to relax and become more cognizant of their behaviors. With learning how to communicate more appropriately and developing a more unified stance, the couple experienced a reduction in their anxiety and became more emotionally regulated and differentiated offering each other connection and their daughter a different form of interaction with boundaries, limits and love. These interactions created the family unit with the parents in charge of the family and the daughter allowed to be a teenage who did not have to try and control the family unit.
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