Families in Psychiatry

Helping patients find balance between self and other


Applying the theories to practice

An adolescent, Jan, does not speak when her mother is in the room. Jan has a small B-self, and her mother has a large B-self. Not only does Jan have to develop a strong B, but she also has to change how she is in relation – she has to change her R-self. For Jan, individual therapy supports the development of a stronger B-self. Working with the patient and her mother, the balance between both B-selves and the joined R-self can be reworked. In essence, the therapist encourages Jan to speak and helps the mother keep her own counsel. This is a situation in which the individual and family intervention are best implemented by the same therapist.

Systemic family therapy, a specific type of family intervention, focuses on how all the R-selves in a family work together as a unit called the family, or F-self. The F-self also has its own family history, as relationship patterns are transmitted and played out through families and play out through subsequent generations. A new type of family therapy called family constellation therapy (FCT) focuses on the F-self as a collection of ancestral selves. This resonates strongly with families who have experienced significant trauma, such as war and Holocaust survivors. FCT is popular in collectivist cultures, where there is a strong belief in the power and influence of ancestors and where the self is understood as an “assemblage of ancestral relationships that often creates problems in the present day.”11 Dr. Bowen recognized this multigenerational pattern as one of his eight fundamental principles.

The patients whom we see often have failing or fractured relationships. They might be stuck in dysfunctional transactional patterns with intimate partners, or they might fail to find a suitable intimate partner. We recognize relational dysfunction such as “codependency,” “symbiosis,” and “enmeshment.” We recognize too much distance, identifying family cutoffs. We still have a long way to go before clinical practice incorporates the importance of assessment and development of healthy relationships in a deep way. A typical question heard across all clinics: Is your partner/family supportive? Not much else is asked in regard to relationships, unless the answer is no. We have yet to develop a good set of inquiring questions that focus on the assessment of healthy relationships.

What can the therapist do to help the patient manage this continual dialectic? The therapist can ask the questions: How important is your B-self versus your R-self? What is the balance between your B-self and your R-self? What do you know about your family or F-self? Is your F-self important to you?


1. Nichols MP and Davis S. Family Therapy: Concepts & Methods, 8th ed. (Boston: Allyn & Bacon, 2008).

2. The Bowen Center for the Study of the Family.

3. Knudson-Martin C. Fam J. 1996 Jul 1. doi: 1066480796043002.

4. Leff J and Vaughn C. Expressed Emotion in Families. (New York: The Guilford Press, 1985).

5. Breitborde NJK et al. J Nerv Ment Dis. 2013 Oct;201(10):833-40.

6. Gurak K and de Mamani AW. Fam Process. 2017;56(2):476-86.

7. Hooley JM et al. J Clin Psychiatry. 2010 Aug;71(8):1017-24.

8. Khafi TY et al. J Fam Psychol. 2015 Aug;29(4):585-94.

9. Santesteban-Echarr et al. J Psychiatr Res. 2017 Apr;87:30-6.

10. Puffer ES et al. PLoS One. 2017 Mar 28;12(3):e0172611.

11. Pritzker SE and WL Duncan. Cult Med Psychiatry. 2019 Sep;43(3):468-95.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of Working With Families in Family Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest.


Next Article: