Family therapy doesn't ask "who is the problem?" but "how is this problem kept going, back and forth, in this family?" The therapist invites family members (not necessarily all of them) to see the pattern that moves them together, and to try a new response.[2,39]
A problem's cause isn't one-sided; it usually comes from both sides, from a pattern, a pattern of interaction … perhaps avoidance brings anxiety, and anxiety brings avoidance.
01
What is family therapy?
1The worldview
Interaction, structure, meaning: three things family therapy looks at
Family therapy (also called systemic family therapy; in Hong Kong you will also see marriage and family therapy and family counselling) treats a family, or the most important relationships around one person, as a whole. It doesn't ask which person has the problem; it asks what the problem is doing in this family and how it is kept going, back and forth. "Systemic" names this way of seeing; it doesn't require the whole family to attend. In the research, systemic therapy has also been done with some members, with couples, in groups, and even with one person.[35,39]
The shared starting point is circular causality: a person's behaviour is both a response to the last move and the cause of the next, so a problem isn't caused from one side but by a pattern of interaction. A mother pushes harder, her son pulls back; he pulls back, she pushes harder. Who pursues and who withdraws is often not personality but who wants the change: a study observing 31 married couples found both partners demanded more when discussing a change they wanted, and withdrew more when discussing a change the other wanted. Moving the problem from "one person" to "between people" is the most basic move in family therapy.[1,18]
Family therapy is a field, not one school. The 1970s and 80s produced four influential traditions: Bowen's family systems theory, Minuchin's structural approach, Haley and Madanes's strategic approach, and the Milan team's systemic approach. From the late 1980s a postmodern turn (narrative, solution-focused, collaborative dialogue) moved the weight from the family's structure to how family members talk about the problem. Many of the family therapies with research behind them today are manualised programmes built for one kind of problem, and don't belong to any one classic school. Below: the worldview they share first, then each in turn.
02
What does a course of family therapy look like?
Now you know how it sees a person and how it works. The next questions: what is it actually like, does it work, and what is it not for?
Family therapy usually assesses first and then starts the work, and the number of sessions depends on the problem and the programme. For example NICE suggests family therapy for adolescent anorexia typically takes 18 to 20 sessions over about a year, and for bulimia about 6 months; the 164-person anorexia trial gave 16 one-hour sessions over 9 months; family intervention for psychosis takes at least 10 sessions over 3 months to a year; in the UK trial, MST lasted 3 to 5 months. When to meet, and who comes, are agreed with the therapist.[22,23,25,31]
1Who comes, and the first meetingThe first meeting is usually with parents and children (sometimes grandparents or other relatives), talking about why you've come and how each sees the problem. The whole family needn't attend; for some problems time alone and time together are both scheduled, and some work is with only some members.
2
03
Family therapy videos
Episodes are in Cantonese.
04
A self-guided path for family relationships
Not ready to see a family therapist? Start with these four steps; you can do them on your own.
Courses
05
Therapists who practise Family therapy
TreeholeHK's counsellors and clinical psychologists use Family therapy to fit what you need, alongside other approaches.
06
Neighbouring approaches
Family therapy borrows from these approaches and they from it; start here to go deeper into any of them.
A branch of the postmodern turn: separating the person from the problem and re-authoring the life story the dominant story hides. Minuchin asked whether this sets aside the real interaction among family members.[4,16]
It too came out of family therapy's circle: less on the causes of the problem, more on exceptions and existing strengths, using the miracle and scaling questions to turn the talk toward the future.[17]
One of family therapy's pioneers: it centres each person's feelings, coping stances and self-worth, and uses experiential methods such as family sculpting to let relatives feel a different way of relating.
Other therapy approaches
FAQ
Does the whole family have to come?
Not necessarily. The first meeting usually includes the relevant relatives, but the therapist decides who comes by the problem; for some problems (adolescent eating disorders, for instance) there are sessions both alone and together, and some work is with only some members, a couple, or even one person. Bowen-style therapy often starts with one family member leading the change. If someone won't come, the people willing can start.[6,23,35]
What is Bowen family therapy?
Bowen family systems therapy was developed by the psychiatrist Murray Bowen: it sees the family as an emotional unit through which anxiety flows, with tension between two people easily eased by pulling in a third. The focus is differentiation of self, holding your own position and feelings while staying connected, and using the genogram to see patterns repeating across generations; the page has more. On the research, a review of studies on the theory's basic concepts found support for links between differentiation and anxiety, marital satisfaction and psychological distress, but very little support for other parts (such as people of similar differentiation marrying, or the specifics of sibling position and triangulation); and there are few trials of it as a complete therapy.
Want someone alongside you?
You can do the exercises on your own. When you're stuck, a trained therapist can take you further.
The schools differ in emphasis, but family therapy usually looks at three things at once: the back-and-forth sequence of what family members do, the family's structure (who is close to whom, who is in charge, who gets pulled in), and how each person explains the problem and one another. Each moves the others: structure decides who responds from which position, interaction replays the structure every day, and meaning makes it seem natural. Each school below comes in through one or two of these layers.
InteractionOne acts, another responds, round and round
StructureWho is close, who is in charge, who is pulled in between
MeaningHow each person explains the problem and one another
Six basic ideas, seen through the same family
These six ideas are family therapy's shared language, from the surface to the depths. They come from clinical observation and theory, and not all are tested: a review of research on Bowen's theory found that lower differentiation went with more anxiety, lower marital satisfaction and more psychological distress, but found little support for the claim that people of similar differentiation marry, for his sibling-position ideas, or for his specific theory of triangulation; separately, a study of adolescents found that being drawn into parental conflict went with more self-blame. So these ideas work better as lenses than as diagnoses.[2,5,19,20]
These ideas help a therapist ask good questions; they don't hand the family conclusions. The therapist checks with the family whether an idea fits their experience, and drops it if not.
1The identified patient
The family places the problem on one person, the "identified patient". The systemic view reads that person's difficulty as one signal of what the whole family is going through.
"Kai games, so Kai is the problem."
2Circular causality
Behaviour isn't set off from one side; it goes back and forth. The question isn't "who started it" but "how does this circle turn?"
The more his mother pushes, the more Kai retreats; the more he retreats, the more she pushes.
3Triangulation
Tension between two people easily pulls in a third to ease it. It cushions in the short term but complicates things later, because the real disagreement is left untouched.
The parents' disagreement about discipline becomes each of them taking a line to Kai: "your mum worries too much", "your dad doesn't care".
4Boundaries
The unspoken rules about who is close to whom and who is responsible for what. Too close (enmeshed) or too distant can each leave someone without space of their own, or without support.
His mother manages every detail of Kai's day and his father hardly any; the two adults hold very different boundaries around the same child.
5Homeostasis
A family tends to keep its established balance. When one person starts to change, the others' reactions can pull them back without anyone meaning to. This is a theoretical idea, and it doesn't mean every family resists change.
One night Kai switches off on time and the family isn't used to it; his mother asks, "What are you up to now?"
6Multigenerational patterns
Bowen held that a family's ways of interacting and reacting emotionally can repeat across generations. The genogram is how the repeated patterns get drawn out.
In the home where Kai's father grew up, answering back meant disrespect; without meaning to, he carries that rule into this one.
2The method
Four classic traditions and the postmodern turn, on one map
Family therapy is a field, not one practice. Each of the five traditions below comes in through one or two of the three layers above; the tag under each card shows which. They don't replace one another, and many therapists blend them to fit the family.[39]
BowenBowen family systems theoryMurray Bowen saw the family as one emotional unit: anxiety moves between relationships, and tension between two people is easily eased by pulling in a third (triangulation). The core idea is differentiation of self: holding your own position and feelings while staying connected. The tool is the genogram, which draws several generations' relationships and events on one chart. See its own page for more.Structure
MinuchinMinuchin's structural family therapySalvador Minuchin looked at the family's structure: who is too close (enmeshed), who too distant, who is in charge, and how these unspoken boundaries keep a problem going. The therapist first joins the family, then asks members to interact in the room (enactment), adjusting boundaries and roles on the spot.StructureInteraction
HaleyHaley and Madanes's strategic therapyJay Haley and Cloé Madanes saw a symptom as one link in how family members interact, often bound up with who has influence and who looks after whom. The therapist sets a clear goal for the problem and designs steps (tasks, or directives) to change the repeating sequence.InteractionStructure
MilanThe Milan systemic approachThe Milan team of Mara Selvini Palazzoli and colleagues treated the interview itself as the intervention: first a hypothesis (hypothesizing) about what the problem does in the family's relationships, then circular questioning, which asks each person how they see the relationships between others, with the therapist staying neutral, taking no one's side.InteractionMeaning
對話The postmodern turn: narrative, solution-focused, collaborative dialogueFrom the late 1980s, Anderson and Goolishian's language-systems approach, White and Epston's narrative therapy and de Shazer's solution-focused brief therapy held that problems and meanings are built in conversation, and that the therapist is not an expert diagnosing the family but a curious conversation partner. Each has its own page for the detail.Meaning
One evening, two readings
BowenKai (15) has gamed until the early hours two nights running. His mother told him five times in one evening to switch off; his father said she was fussing too much.
Looking at one personSeeing the loop
Actions: his mother
Looking at one personCalls five times, louder each time: "He just has no sense of responsibility."
Seeing the loopStarts with: "I'm worried you're not getting enough sleep", then asks how he'd like to plan it.
Actions: Kai
Looking at one personPuts on his headphones and shuts the door.
Seeing the loopFinds it easier to say: "One more game, then I'll stop."
Position: his father
Looking at one personSteps in to say she is fussing; the two adults argue, and Kai can ignore them both.
Seeing the loopNotices he has been pulled into a triangle, agrees with his wife who does what, then they speak to Kai together.
3The skills
Eight practices, each working on one layer
Inside the therapy room, the worldview above becomes specific practices. Each works on one of the three layers: seeing the interaction, adjusting the structure, or changing the meaning; each says which tradition it comes from. In practice therapists blend them to fit the family.
Seeing the interaction
Work out who comes, how the problem unfolds back and forth, and draw the generations behind it.
Assessment: who comes, and how the problem goes round
The first step isn't finding a cause; it is working out who is affected, who comes, and the sequence of the problem at home: how it usually starts, what each person does, how it ends. The therapist also learns each person's view separately, including whether anyone is afraid of another, and then decides whether meeting together is safe and suitable. For some problems (adolescent eating disorders, for example) guidelines set aside time both alone and together; some families see only a few of their members.[3,23,45]
The genogram: drawing the generations
A genogram is a family tree with relationships added: symbols mark marriages, separations, illnesses, moves and other key events across generations, and lines show whether each pair is close, distant or in conflict. Bowen-trained therapists use it to spot repeating patterns; therapists from other traditions also use it to understand the background with the family. The drawing itself often prompts stories that haven't been told before.[6,7]
Circular questions: asking about relationships, not causes
Circular questions come from the Milan team: instead of asking "why do you do this?", they ask one person how they see the relationship between others, the order of events, or differences ("Of your parents, who worries most about him?" "If he stopped, who at home would find it hardest to get used to?"). These let each person hear the loop through someone else's eyes, which often opens up new thinking more readily than direct explanation. Tomm separated this kind of question from linear questions that ask only about individual causes; the therapist asks with curiosity and takes no one's side.[11,12,13]
+Hear it in a session
Therapist
I'd like to ask you three some questions about the relationships between you, not to work out who is right. Each of you only says what you see, and you can skip any you'd rather not answer. Is that all right?
Client
Mother: Yes.
Client
Kai: Mm, OK.
Therapist
Kai, when your mum starts telling you to switch off, what do you think your dad usually does?
Adjusting the structure
Build a relationship with each person first, then let the family interact in the room and adjust boundaries and positions.
Joining: becoming someone the family can trust
Minuchin called it joining: before proposing any change, the therapist accepts the family's way of talking, its rules and its rhythm, and builds a relationship with each person (including a reluctant teenager), so that each feels heard rather than judged. Without this step, later change rarely happens.[2,3]
Enactment: asking the family to talk to each other in the room
A core structural move: the therapist asks family members to talk about a problem directly in the room, instead of reporting it to the therapist. This shows how they really interact, and allows on-the-spot intervention: asking the person pulled in to step out for now, or asking the two adults to agree between them first before speaking to the child, shifting a boundary a little. Order matters: it needs enough joining first and isn't where therapy starts.[2,3]
+Hear it in a session
Therapist
Changing the meaning
Say the same thing another way, then set small steps to try at home.
Reframing: saying the same thing another way
Reframing puts an event in a different frame so its meaning shifts while the facts stay the same: "he won't listen" becomes "he is learning to make his own decisions"; "she controls too much" becomes "she worries a lot about him". The Milan team called this kind of statement a positive connotation: naming the good intent or function of each person's behaviour within this family. A good reframe has to fit the family's experience; if someone feels brushed aside, it should be dropped.[10,11]
Tasks: small steps to try at home
Strategic therapists often end a session by giving the family a clear, limited task: "this week, agree on a switch-off time between the two of you, then tell Kai together", or asking one person to notice when a loop begins. The aim is to break the repeating sequence in everyday life and review what happened next session. A task should be one the family agrees to, can do, and understands the reason for.[8,9]
The dialogues are illustrative composites, not real clients; skills that stir strong emotion or touch on trauma should be done with a trained therapist.
Assessment: the pattern and the genogramThe therapist treats the problem as a pattern: how it usually starts, who does what, how it ends; may draw a genogram to understand the generations; and watches for anyone being afraid of another, perhaps meeting people separately to decide whether joint sessions are safe and suitable.
3Joining and setting goalsThe therapist builds a relationship with each person and together you set goals the family really wants, such as "sleep and routine" or "meals without fighting", not "fix one person".
4Working in the roomUsing the practices above: circular questions, reframing, enactments, and tasks to try at home. Between sessions the family tries new responses in daily life and brings back what happened.
5Consolidating and endingReview what has changed, plan for when the old pattern returns, and space sessions out. At the end, plan too for preventing relapse.
What can family therapy help with?
Research supports it most for certain specific problems in children, adolescents and adults; family therapy is also used for conflict between family members and major transitions, where there is less research.[39,40]
Adolescent anorexia and bulimia
Adolescent conduct problems and substance use
Relapse prevention when a relative has psychosis
Emotional difficulties in children and adolescents
A family adjusting to a relative's chronic illness
Repeating conflict between parents and children
Major transitions such as divorce, a blended family or a move
Disagreements among relatives caring for an older family member
Family therapy is not for a family where there is violence, abuse or control: if someone uses violence, threats or control so that another person is afraid, speaking honestly in front of them can be more dangerous, and safety comes first. If you are facing domestic violence, talk to a social worker (Social Welfare Department hotline 2343 2255) or Harmony House (24-hour women's hotline 2522 0434; men's hotline 2295 1386), and in an emergency call the police (999). If you are thinking of hurting yourself or ending your life, call The Samaritans' 24-hour line on 2896 0000.
Does it work? What the research says
The evidence for family therapy varies a lot by problem: fairly firm for some, still thin for others. Most importantly, most trials test manualised programmes designed for one problem, not Bowen's, Minuchin's or the Milan school itself. Each item below is rated, firmest first.
Psychosis: involving the family can reduce relapse
More evidence neededSufficient evidenceSolid evidence
A large 2022 review found that nearly all family intervention models cut relapse at 12 months compared with usual care. UK guidance (NICE) says to offer family intervention to all families who live with or are in close contact with someone with psychosis (at least 10 sessions over 3 months to 1 year). But note: these programmes are mostly education about the illness and support for the family, not classic systemic therapy; the review found family education alone did no worse than more complex models. The authors also say confidence in the comparisons ranged from moderate to very low.[21,22]
Adolescent anorexia: family-based treatment is first choice, but the evidence has limits
More evidence neededSufficient evidenceSolid evidence
NICE says to consider anorexia-focused family therapy for children and young people (typically 18 to 20 sessions over about a year). In a trial of 121 teenagers, family-based treatment and individual therapy for the teenager had similar recovery rates at the end, but family-based treatment had more full recoveries at 6 and 12 months after. A trial of 164 found family-based treatment, which concentrates on eating and weight, did about as well as a more general systemic family therapy, at lower cost. The Cochrane review is more cautious: only a little low-quality evidence that it beats usual treatment in the short term, and it couldn't tell whether it has an advantage over other psychological therapies.[23,24,25,26]
Adolescent bulimia: one trial found family therapy beat supportive therapy
More evidence neededSufficient evidenceSolid evidence
In a trial of 80 teenagers, family-based treatment got more young people to stop binge-eating and purging than supportive psychotherapy: about 4 in 10 against about 2 in 10 at the end, and about 3 in 10 against about 1 in 10 six months later. NICE says to offer bulimia-focused family therapy to children and young people with bulimia (typically 18 to 20 sessions over about 6 months). The limit is that this rests mainly on one trial, and not a large one.[23,27]
Adolescent substance use: family therapy has relatively the strongest evidence
More evidence neededSufficient evidenceSolid evidence
A review pooling 45 studies found family therapy programmes did better than their comparison conditions and judged that, among outpatient treatments for adolescent substance use, family therapy has relatively the strongest evidence, though not every treatment was compared head to head. A second review of 24 studies on four well-known family models (brief strategic, functional, multidimensional and multisystemic) for adolescent delinquency and substance use found modest effects against usual or other treatment, and couldn't say which model is best.[28,29]
Adolescent antisocial behaviour: recommended by UK guidance, but a large trial found no advantage
More evidence neededSufficient evidenceSolid evidence
NICE says to offer multimodal interventions such as multisystemic therapy (MST, a programme that works across the individual, family, school, criminal justice and community levels) to 11- to 17-year-olds with conduct disorder. But a UK trial of 684 families found MST no better than usual management at reducing out-of-home placement at 18 months, and no different in criminal convictions at 5 years. A Cochrane review judged the evidence inconclusive, and a pooled analysis found small effects that varied by country and study quality. That doesn't mean family-based work is useless for these problems; it means more research in more places is needed.[30,31,32,33,34]
Other problems, and the classic schools themselves: positive signs, few trials
More evidence neededSufficient evidenceSolid evidence
Several reviews have pooled trials of "systemic therapy". In adults, 38 trials were found, 34 of them positive; a separate pooled analysis found it did better than no treatment and about as well as other established psychotherapies, but only for a few conditions (eating disorders, mood disorders and psychosis, among them) were there enough trials. In children and adolescents there are 47 trials on externalising problems (such as attention-deficit, conduct and substance problems) and 38 on internalising ones. Carr's large survey also finds the evidence supports family-based work for many child and adult problems, though it counts family-based approaches such as parent training too. NICE lists family therapy as one fallback for 12- to 18-year-olds with moderate to severe depression, after individual cognitive behavioural therapy. But Bowen's, Minuchin's, the strategic and Milan models have rarely been tested as complete programmes; research on Bowen's theory supports only parts of its concepts.[19,35,36,37,38,39,40,41]
To be honest: the best evidence for family therapy comes mainly from manualised programmes built for particular problems (above all adolescent eating disorders, substance use and psychosis), and the helpful element is often helping parents or relatives to support the patient more effectively, not necessarily the systemic theory itself; the anorexia trials show a programme concentrating on eating did about as well as a general systemic family therapy. Reviews that pool the trials often count how many trials were positive, without showing whether each compared against a trustworthy alternative; and the trials come mostly from the US and Europe with a few from China, so how well they apply to Hong Kong families isn't known. That doesn't make family therapy useless; it means that, beyond the school, training in the problem you face matters just as much.[25,35,36,39]
To be honest: family therapy's limits and critiques
Family therapy has real evidence behind it, but it has clear limits and has faced strong criticism: its early theory could overlook power, and put the blame on parents.[42,43,44]
1Not for families with violence, abuse and control
If someone uses violence, threats or control so that another person is afraid, meeting together isn't safe and safety comes first. That's why responsible family therapists get to know each person separately before starting, and watch for children's safety. Only in some cases, where nobody is afraid of anyone else, do professionals assess whether to work together.
2"Neutrality" and circular causality can overlook differences in power
In 1984 Bograd argued that systemic approaches to wife battering carry biases against women in theory and practice; Goldner argued systems theory is an inadequate account of the family and ignores gender power within it; Hare-Mustin had earlier pointed out that family therapy often reinforces stereotyped sex roles without noticing. The critique is a reminder that saying two people "move each other" does not mean equal responsibility, and certainly not that a person who is harmed answers for the violence. Cecchin of the Milan group later reworked neutrality as a form of curiosity.
3Placing the blame on parents
Early family therapy often put problems down to the parents, mothers above all; Goldner argued that the so-called "overinvolved mother and peripheral father" is better understood within history and society, not as a fault in particular families. Today's research-backed programmes (for example family therapy for bulimia) explicitly require not blaming the patient, family members or carers, and treat the family as a resource for recovery.
4The classic schools have seldom been tested on their own
Most of the evidence is for manualised programmes for particular problems; research on Bowen's theory supports only parts of its concepts; and the adolescent anorexia trial found a programme focused on eating did about as well as general systemic family therapy. So don't take a school's name as a guarantee of results.
5It takes time, and family members who are willing to come
Family therapy often takes a dozen to twenty sessions and needs the relevant family members to take part; if someone refuses to come, the therapist may work with those who do. It doesn't replace other treatment that is needed: family intervention for psychosis, for example, is offered alongside medication and other treatment.
That's why a good family therapist first makes sure joint work is safe, then blends practices to fit the problem and the family. Family therapy is a place where a family can see its loop together, not a court that rules on who's right.
Bowen family systems therapyOne of family therapy's four classic traditions: differentiation of self, triangles, the genogram and patterns passed down the generations, covered in more detail on its own page.[5]
Couples therapyApplies family therapy's loop thinking to two people: how pursuing and withdrawing keep each other going, and the feelings and needs beneath the loop.
Psychodynamic therapyBoth care how early family relationships shape the present: psychodynamic therapy attends to the person's inner world, family therapy to how relationship patterns go back and forth and pass down the generations.[5]
They share a root: both use circular causality to read a problem. The difference is who attends and which relationships are worked on. Couples therapy works on the relationship between two people; family therapy's unit is the family, often including children and parents, and it also works on triangles and boundaries between generations. In Hong Kong many therapists' training (such as marriage and family therapy) covers both. For couples therapy in detail, see the couples therapy page.[2,18]
If a child has a problem, is it the parents' fault?
No. Early family therapy sometimes put problems down to parents, especially mothers, and that has been strongly criticised. Family therapy with research behind it today, such as the programme for bulimia, explicitly requires not blaming the patient, family members or carers. Circular causality says people move each other, not that one person should be blamed; parents are usually the key resource in a child's recovery.[23,42]
How do I find a family therapist in Hong Kong, or train in family therapy?
Look for specific training in marriage and family therapy and membership of a professional body. The Hong Kong Marriage and Family Therapy Association has a Certified Marriage and Family Therapist membership that requires relevant master's-level training, client contact hours and supervision; further down are the counsellors who offer family therapy. To train, the Hong Kong Polytechnic University offers a Master of Arts in Marriage and Family Therapy (about 1.5 years full-time or 3 years part-time, with intakes in alternate years), and its clinical training counts toward half of the client contact hours needed for clinical membership of the American Association for Marriage and Family Therapy (AAMFT). Check each organisation for current details.[47,48]
Can we do family therapy if there's violence at home?
If someone uses violence, threats or control so that another person is afraid, family therapy is not appropriate, because speaking honestly in front of them could put you at more risk. Look after your safety first: talk to a social worker (Social Welfare Department hotline 2343 2255) or Harmony House (24-hour women's hotline 2522 0434; men's hotline 2295 1386), and in an emergency call the police (999). Responsible family therapists get to know each person separately before starting; if a child is being harmed, protecting the child comes before doing therapy together.[44,45,46]
2.Minuchin, S. (1974). Families and family therapy. Harvard University Press.
3.Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Harvard University Press.
4.Minuchin, S. (1998). Where is the family in narrative family therapy? Journal of Marital and Family Therapy, 24(4), 397–403. doi.org/10.1111/j.1752-0606.1998.tb01094.x
5.Bowen, M. (1978). Family therapy in clinical practice. Jason Aronson.
6.Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. W. W. Norton.
7.McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and intervention (3rd ed.). W. W. Norton.
8.Haley, J. (1976). Problem-solving therapy. Jossey-Bass.
9.Madanes, C. (1981). Strategic family therapy. Jossey-Bass.
10.Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. W. W. Norton.
11.Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing—circularity—neutrality: Three guidelines for the conductor of the session. Family Process, 19(1), 3–12. doi.org/10.1111/j.1545-5300.1980.00003.x
12.Cecchin, G. (1987). Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process, 26(4), 405–413. doi.org/10.1111/j.1545-5300.1987.00405.x
13.Tomm, K. (1988). Interventive interviewing: Part III. Intending to ask lineal, circular, strategic, or reflexive questions? Family Process, 27(1), 1–15. doi.org/10.1111/j.1545-5300.1988.00001.x
14.Anderson, H., & Goolishian, H. A. (1988). Human systems as linguistic systems: Preliminary and evolving ideas about the implications for clinical theory. Family Process, 27(4), 371–393. doi.org/10.1111/j.1545-5300.1988.00371.x
15.Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir model: Family therapy and beyond. Science and Behavior Books.
16.White, M., & Epston, D. (1990). Narrative means to therapeutic ends. W. W. Norton.
17.de Shazer, S. (1985). Keys to solution in brief therapy. W. W. Norton.
18.Christensen, A., & Heavey, C. L. (1990). Gender and social structure in the demand/withdraw pattern of marital conflict. Journal of Personality and Social Psychology, 59(1), 73–81. doi.org/10.1037/0022-3514.59.1.73
19.Miller, R. B., Anderson, S., & Keala, D. K. (2004). Is Bowen theory valid? A review of basic research. Journal of Marital and Family Therapy, 30(4), 453–466. doi.org/10.1111/j.1752-0606.2004.tb01255.x
20.Fosco, G. M., & Grych, J. H. (2010). Adolescent triangulation into parental conflicts: Longitudinal implications for appraisals and adolescent–parent relations. Journal of Marriage and Family, 72(2), 254–266. doi.org/10.1111/j.1741-3737.2010.00697.x
21.Rodolico, A., Bighelli, I., Avanzato, C., Concerto, C., Cutrufelli, P., Mineo, L., … Leucht, S. (2022). Family interventions for relapse prevention in schizophrenia: A systematic review and network meta-analysis. The Lancet Psychiatry, 9(3), 211–221. doi.org/10.1016/S2215-0366(21)00437-5
22.National Institute for Health and Care Excellence. (2014). Psychosis and schizophrenia in adults: Prevention and management (NICE guideline CG178), recommendations 1.3.7.2, 1.4.4.2 and 1.5.4.2. nice.org.uk
23.National Institute for Health and Care Excellence. (2017). Eating disorders: Recognition and treatment (NICE guideline NG69), recommendations 1.3.10–1.3.14 and 1.5.6–1.5.8. nice.org.uk
24.Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025–1032. doi.org/10.1001/archgenpsychiatry.2010.128
25.Agras, W. S., Lock, J., Brandt, H., Bryson, S. W., Dodge, E., Halmi, K. A., … Woodside, B. (2014). Comparison of 2 family therapies for adolescent anorexia nervosa: A randomized parallel trial. JAMA Psychiatry, 71(11), 1279–1286. doi.org/10.1001/jamapsychiatry.2014.1025
26.Fisher, C. A., Skocic, S., Rutherford, K. A., & Hetrick, S. E. (2019). Family therapy approaches for anorexia nervosa. Cochrane Database of Systematic Reviews, 2019(5), CD004780. doi.org/10.1002/14651858.CD004780.pub4
27.le Grange, D., Crosby, R. D., Rathouz, P. J., & Leventhal, B. L. (2007). A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry, 64(9), 1049–1056. doi.org/10.1001/archpsyc.64.9.1049
28.Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta-analysis. Journal of Substance Abuse Treatment, 44(2), 145–158. doi.org/10.1016/j.jsat.2012.05.006
29.Baldwin, S. A., Christian, S., Berkeljon, A., & Shadish, W. R. (2012). The effects of family therapies for adolescent delinquency and substance abuse: A meta-analysis. Journal of Marital and Family Therapy, 38(1), 281–304. doi.org/10.1111/j.1752-0606.2011.00248.x
30.National Institute for Health and Care Excellence. (2013). Antisocial behaviour and conduct disorders in children and young people: Recognition and management (NICE guideline CG158), recommendation 1.5.13. nice.org.uk
31.Fonagy, P., Butler, S., Cottrell, D., Scott, S., Pilling, S., Eisler, I., … Goodyer, I. M. (2018). Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): A pragmatic, randomised controlled, superiority trial. The Lancet Psychiatry, 5(2), 119–133. doi.org/10.1016/S2215-0366(18)30001-4
32.Fonagy, P., Butler, S., Cottrell, D., Scott, S., Pilling, S., Eisler, I., … Goodyer, I. M. (2020). Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): 5-year follow-up of a pragmatic, randomised, controlled, superiority trial. The Lancet Psychiatry, 7(5), 420–430. doi.org/10.1016/S2215-0366(20)30131-0
33.Littell, J. H., Campbell, M., Green, S., & Toews, B. (2005). Multisystemic therapy for social, emotional, and behavioral problems in youth aged 10–17. Cochrane Database of Systematic Reviews, (4), CD004797. doi.org/10.1002/14651858.CD004797.pub4
34.van der Stouwe, T., Asscher, J. J., Stams, G. J. J. M., Deković, M., & van der Laan, P. H. (2014). The effectiveness of multisystemic therapy (MST): A meta-analysis. Clinical Psychology Review, 34(6), 468–481. doi.org/10.1016/j.cpr.2014.06.006
35.von Sydow, K., Beher, S., Schweitzer, J., & Retzlaff, R. (2010). The efficacy of systemic therapy with adult patients: A meta-content analysis of 38 randomized controlled trials. Family Process, 49(4), 457–485. doi.org/10.1111/j.1545-5300.2010.01334.x
36.von Sydow, K., Retzlaff, R., Beher, S., Haun, M. W., & Schweitzer, J. (2013). The efficacy of systemic therapy for childhood and adolescent externalizing disorders: A systematic review of 47 RCT. Family Process, 52(4), 576–618. doi.org/10.1111/famp.12047
37.Retzlaff, R., von Sydow, K., Beher, S., Haun, M. W., & Schweitzer, J. (2013). The efficacy of systemic therapy for internalizing and other disorders of childhood and adolescence: A systematic review of 38 randomized trials. Family Process, 52(4), 619–652. doi.org/10.1111/famp.12041
38.Pinquart, M., Oslejsek, B., & Teubert, D. (2016). Efficacy of systemic therapy on adults with mental disorders: A meta-analysis. Psychotherapy Research, 26(2), 241–257. doi.org/10.1080/10503307.2014.935830
39.Carr, A. (2019). Family therapy and systemic interventions for child-focused problems: The current evidence base. Journal of Family Therapy, 41(2), 153–213. doi.org/10.1111/1467-6427.12226
40.Carr, A. (2019). Couple therapy, family therapy and systemic interventions for adult-focused problems: The current evidence base. Journal of Family Therapy, 41(4), 492–536. doi.org/10.1111/1467-6427.12225
41.National Institute for Health and Care Excellence. (2019). Depression in children and young people: Identification and management (NICE guideline NG134), recommendations 1.6.4–1.6.6. nice.org.uk
44.Bograd, M. (1984). Family systems approaches to wife battering: A feminist critique. American Journal of Orthopsychiatry, 54(4), 558–568. doi.org/10.1111/j.1939-0025.1984.tb01526.x
45.Bograd, M., & Mederos, F. (1999). Battering and couples therapy: Universal screening and selection of treatment modality. Journal of Marital and Family Therapy, 25(3), 291–312. doi.org/10.1111/j.1752-0606.1999.tb00249.x
Looking at one personThe more she pushes, the more Kai retreats and the more his father shields him; all three feel misunderstood.
Seeing the loopOne small step at a time; each person is pushed less into a fixed position.
The right-hand column shows what can shift once a family sees the loop in therapy. The mother's pushing, Kai's retreat and the father's stepping in together kept the circle going; once they see it, each has a chance to change one step. This is an imagined family: nobody is judged "wrong", and it doesn't mean the gaming isn't a problem; it's that the first job is to see how the problem is kept going among the three. Real family therapy decides who comes and what is discussed according to each family's situation and wishes.
Client
Kai: He says "leave it", and then the two of them argue.
Therapist
And when they start arguing, what do you do?
Client
Kai: I put my headphones on.
Therapist
Dad, when Kai puts his headphones on, what do you think his mum does?
Client
Father: She calls even harder.
Therapist
Mum, how is it to hear that?
Client
Mother: I'm not trying to fight; I'm afraid his grades and his health will go.
Therapist
Here is the circle I hear: the more worried Mum is, the more she pushes; the more Kai is pushed, the more he withdraws; Dad steps in to shield him, the two adults argue, and Kai withdraws further. Does that circle look like your home? Please correct anything I've got wrong.
Client
Father: More or less. But I'm not shielding him; I think she's too tense.
Therapist
Thank you for correcting me; we'll put both versions on the picture. This week, could you each just notice one time the circle starts, without having to change anything?
Client
Kai: I can do that. But I still want to game.
Therapist
That's a clear wish, and we'll come back to it properly.
Notice: This shows circular questioning. The therapist asks permission and says this isn't about who is right; the questions are about relationships and differences, each person answers only for what they see, not for others; the therapist offers no explanation, only links what has been said and asks each person whether it fits. Kai loosens only a little and his mother still worries, which is normal: seeing the loop is a beginning, not an end.
I heard that you two have different ideas about gaming time. Could you try, instead of telling me, talking it over directly with each other, while Kai listens? Is that OK?
Client
Mother: (turning to her husband) You always say "leave it", and then I'm left being the bad guy on my own.
Client
Father: I just think you keep pushing and he's sick of it. Ask Kai, he'll tell you himself—
Therapist
I notice the conversation has turned to Kai again. For this part I'd like the two of you to talk: for gaming time, what does each of you want?
Client
Father: I'd like it off by eleven on school nights.
Client
Mother: I'd like eleven too. I thought you wanted to leave it entirely.
Therapist
What did you just find out?
Client
Father: Our views are quite close; we've just never put it like that.
Therapist
Kai, how was it listening to them talk like that? Say something if you want to; you don't have to.
Client
Kai: Quieter than usual. But eleven is too early.
Therapist
We'll keep that for the next step, for all three of you to work out. Today the two of you have tried talking without going through Kai.
Notice: This shows an enactment. The therapist asks the parents to talk directly and steps back to observe; when the old pattern appears (both turn to Kai again), the therapist gently brings the topic back between the two adults and keeps a place for Kai out of the middle. The conversation stays stiff and only a little different: it's a start.
Standing as yourself: holding your own position within the relationship
Bowen-style therapy often starts with one person changing: the therapist coaches a family member to say, calmly and while anxiety is rising, "My view is…, and I will…", without attacking, retreating or placating, and to notice when they are being drawn into a triangle. The aim is differentiation of self: staying connected without being led by someone else's anxiety. This is usually a long practice.[5,6]
