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Instructor’s Resource Manual and Test Bank for

Family Therapy: History, Theory, and Practice

7^th Edition

Samuel T. Gladding

Wake Forest University

Contents

Prologue Rationale For Family Therapy 1

Chapter 1 The History of Family Therapy: Evolution and Revolution 2

Chapter 2 The Theoretical Context of Family Therapy 10

Chapter 3 Types and Functionality of Families 18

Chapter 4 Working with Single-Parent and Blended Families 26

Chapter 5 Working with Culturally Diverse Families 38

Chapter 6 Ethical, Legal, and Professional Issues in Family Therapy 48

Chapter 7 The Process of Family Therapy 63

Chapter 8 Couple and Marriage Therapy and Enrichment 74

Chapter 9 Psychodynamic Family Theory 86

Chapter 10 Bowen Family Systems Theory 92

Chapter 11 Behavioral and Cognitive-Behavioral Family Therapies 98

Chapter 12 Experiential Family Therapy 108

Chapter 13 Structural Family Therapy 117

Chapter 14 Strategic Family Therapies 125

Chapter 15 Solution-Focused Brief Therapy 133

Chapter 16 Narrative Family Therapy 139

Chapter 17 Research and Assessment in Family Therapy 144

Chapter 18 Working with Substance-Related Disorders, Domestic Violence, and Child Abuse 153

Answer Key 163

Prologue

Approximately 19% of the U.S. population is seen by marriage and family therapists each year at a cost of more than $300 million
Despite these statistics, marriage and family therapy is relatively new with its theoretical and clinical beginnings starting in the 1940s and its real growth occurring from the 1970s until today
Family therapy differs from individual and group counseling in its emphasis and clientele
- Individual counseling is more intrapersonal
- Group counseling is more interpersonal
- Family therapy for the most part focuses on making changes in the family system
Family therapy is connected to the influence of creative, innovative, and assertive mental health practitioners who devised and advocated new ways of providing services to clients

The Rationale for Family Therapy

Family therapists believe that most life difficulties stem from and can best be addressed within the family system
Family therapy is an effective treatment approach, particularly in cases of:
adolescent anorexia nervosa
adolescent drug abuse
adult alcoholism and drug abuse
adult hypertension
adult obesity
adult schizophrenia
aggression and noncompliance in children with ADD and ADHD
childhood and adolescent anxiety disorders
childhood autism
childhood conduct disorders
chronic physical illness in adults and children
couple distress and conflict
dementia
depression in women in distressed marriages
Client satisfaction is high, with 97% satisfaction rates and high percentages of clients stating they received the help they wanted from marriage and family therapists

Reasons for Working with Families as Opposed to Working with Individuals

Provides flexibility in conceptualizing cases from both linear and circular causality perspectives
Provides for increased complexity and treatment options for clients
Involves other real, significant people in the treatment process and brings the action into the room
All family members receive treatment interventions simultaneously
Family therapy tends to be briefer than individual counseling
Family therapy focuses on the interpersonal rather than the intrapersonal which creates new and unique ways of resolving problems

Chapter 1

The History of Family Therapy: Evolution and Revolution

Chapter Overview

Family Therapy Through the Decades

Prior to the development of marriage and family therapy as a profession, older family members assisted younger members and adult family members cared for the very young and the very old
Before 1940
focus in the United States was on the individual
society utilized clergy, lawyers, and doctors for advice and counsel
prevailing individual theories were psychoanalysis and behaviorism
Catalysts for the growth of family therapy
courses in family life education became popular
establishment of marriage and family training programs (e.g., Marriage Council of Philadelphia in 1932)
founding of the National Council on Family Relations in 1938 and the journal Marriage and Family Living in 1939
county home extension agents educated and promoted understanding family dynamics
Family therapy: 1940 to 1949
establishment of the American Association of Marriage Counselors in 1942
first account of concurrent marital counseling published in 1948 by Bela Mittleman
research on families with a schizophrenic member by Theodore Litz
National Mental Health Act of 1946 funded research on prevention, diagnosis, and treatment of mental health disorders
Family therapy: 1950 to 1959
individual leaders dominated the profession
Nathan Ackerman used a psychoanalytical approach to understand and treat families
Gregory Bateson studied communication patterns in families with a schizophrenic member and developed the double bind theory
double bind theory - two seemingly contradictory messages may exist simultaneously and lead to confusion
Mental Research Institute was created by Don Jackson in Palo Alto, CA
changed problem conceptualization from a pathology oriented individual perspective to a more relationship based orientation
brief therapy developed at MRI as one of the first new approaches to family therapy
Carl Whitaker pushed the conventional envelope by seeing spouses and children in therapy
set up the first family therapy conference at Sea Island, GA
Murray Bowen studied families with schizophrenic members
held therapy sessions with all family members present
pioneered theoretical thinking on the influence of previous generations on the mental health of families
Ivan Boszormenyi-Nagy developed contextual therapy focusing on the healing of human relationships through trust and commitment
Family therapy: 1960 to 1969
An era of rapid growth in family therapy
Increase in training centers and academic programs in family therapy
Jay Haley, expanding on the work of Milton Erikson, developed strategic family therapy
emphasis on the therapist gaining and maintaining power during treatment
strategic therapy uses directives to assist clients to go beyond gaining insight
edited Family Process from 1961 to 1969, providing a means for to keep professions linked and informed
Haley joined with Salvador Minuchin at the Philadelphia Child Guidance Clinic in the late 1960's
Salvador Minuchin developed structural family therapy, based on his work with the Wiltwyck School for Boys
utilized minority community members as paraprofessionals to better relate to urban blacks and Hispanics
Virginia Satir was the only woman among the family therapy pioneers
started seeing family members as a group in the 1950's
utilized touch and nurtured her clients, emphasizing self-esteem, compassion, and affective congruence
published Conjoint Family Therapy in 1964 which stressed the importance of seeing distressed couples together at the same time
Virginia Satir was an influential, charismatic leader
Carl Whitaker pioneered unconventional, spontaneous, sometimes outrageous appearing approaches, designed to help families achieve freedom and growth
Family Process co-founded in 1961 by Don Jackson and Nathan Ackerman
Nathan Ackerman published Treating the Troubled Family in 1966, advocating closer therapist involvement with families during treatment, being confrontive, and making covert issues overt
John Bell developed a family group therapy model, advocated that children 9 years and older should participate in family therapy, and offered one of the first graduate family therapy courses in the United States
Murray Bowen discovered that emotional reactivity in many families created undifferentiated family ego mass (i.e., family members have difficulty maintaining their individual identities and actions)
Systems theory developed by Ludwig Von Bertalanffy in 1968
a way of looking at all parts of an organism simultaneously
a set of elements standing in interaction with one another
each element of a system is affected by what happens to any other element
the whole is greater than the sum of its parts
became the basis for most family therapy
less reliance on linear causality (direct cause and effect)
increased emphasis on circular causality (events are related through a series of repeating cycles or loops)
family therapists seen as a specialists within the field
first license regulating family therapists granted in California in 1963
Institutes and training centers
- Mental Research Institute continues its work in training and research
- Family Therapy Institute of New York established with Nathan Ackerman as director
- Philadelphia Child Guidance Clinic developed innovative supervision techniques such as the 'bug in the ear"
- Family Therapy Institute of Philadelphia founded in 1964, merging the Eastern Pennsylvania Psychiatric Institute and the Family Institute of Philadelphia
- Boston Family Institute founded by Fred Duhl and David Kantor, focusing on expressive and dramatic interventions and originating the family sculpting technique
- Institute for Family Studies in Milan, Italy formed in 1967
- an MRI based model that developed many innovative short term approaches
Family therapy: 1970 to 1979
- rapid growth in AAMFT based partly on recognition as an accrediting body for marriage and family training programs
- The American Association of Marriage and Family Counselors (AAMFC) changed its name to the American Association for Marriage and Family Therapy (AAMFT) in 1977
- Journal of Marital and Family Therapy founded by AAMFT in 1974
- American Family Therapy Academy (AFTA) founded in 1977 to address clinical, research, and teaching issues
- AAMFT and AFTA agreed on distinct roles within the profession
- AFTA concentrated on the exchange of ideas among advanced professionals
- AAMFT focused on accreditation of training programs
- family therapy continued to growth and become more refined outside of psychoanalytical traditions
- Nathan Ackerman died in 1971
- the approaches of Carl Whitaker (experiential family therapy), Salvador Minuchin (structural family therapy), and Jay Haley (strategic family therapy) gained in popularity and influence
- Families and Family Therapy published in 1974 by Minuchin, serving as a practical training guide for structural family therapy
- Psychosomatic Families: Anorexia Nervosa in Context published by Minuchin and associates in 1978, highlighting the power of the structural family therapy approach in working with this disorder
Influence of foreign therapies and therapists
family therapy grew rapidly in Europe, particularly in Milan, Italy
Milan associates
developed circular questioning (asking questions that highlight differences among family members)
developed triadic questioning (asking a third member how two other members of the family relate)
emphasis on developing hypotheses about the family before treatment begins
utilized outside of session homework assignments that were often difficult and ritualistic
R.D. Laing, a British professional, created the term mystification to describe how some families mask interactions between family members by giving contradictory or confusing explanations
Robin Skynner, from Great Britain, developed a brief psychoanalytic family therapy which complemented the earlier work of Nathan Ackerman and Ivan Boszormenyi-Nagy
Feminist theory and family therapy
feminists began to question whether or not some concepts of family therapy were oppressive to women
A Feminist Approach to Family Therapy was published in Family Process by Rachel Hare-Mustin in 1978
belief that sexism limits the psychological well-being of women and men and must not be tolerated
Family therapy: 1980 to 1989
marked by the retirement or death of many family therapy founders and leaders and the emergence of new leaders
increase numbers of women leaders who created new theories which challenged older ones
Women's Project in Family Therapy in 1988 focused on gender free approaches to family therapy
increased numbers of individuals and associations devoted to family therapy, including the International Association for Marriage and Family Counseling (IAMFC) of the American Counseling Association and Division 43 (Family Psychology) of the American Psychological Association
increased levels of research in family therapy to provide evidence of the effectiveness of family therapy
increased numbers of publication in the family therapy field, including the Family Therapy Networker
Creation of multisystemic therapy, an intensive family- and community-based approach for working with juvenile offenders
recognition of family therapy as one of four core mental health providers eligible for federal training grants
Family therapy: 1990 to 1999
- family therapy became a more worldwide phenomenon, with associations, research, and training institutes established across the globe
- new theories were developed or refined
- feminist family therapy examined gender sensitive issues in therapy rather than masculine or feminine issues, per se
- the reflecting team approach of Tom Anderson used clinical observers to discuss their impressions with the therapist and the family, thus becoming a part of the therapeutic team
- the therapeutic conversations model of Harlene Anderson and Harry Goolishian used a postmodern approach in which the therapist relates to the family in a more collaborative, egalitarian partnership
- the psychoeducational model of Carol Anderson emphasized teaching family members about multiple aspects of mental illness, focusing on boundaries, hierarchy, and the integrity of subsystems
- the internal family systems model of Richard Schwartz looks at both individual intrapsychic dynamics and family systems
- social constructionism based models were radically different than systems based models in that they are based on the belief that our experiences are a function of how we think about them rather than objective truths
- Basic Family Therapy Skills Project was established in 1987 to determine the essential skills needed for mastery of structural, strategic, brief, and transgenerational family therapy approaches
- increased awareness and focus on the influence of the therapist on the therapy (second-order cybernetics)
- increased importance of the family ontology or 'world view' stressing circularity and autonomy of systems
- change in training emphasis from producing narrowly focused, theory bound clinicians to a focus on how to work with specific populations or types of families
Family therapy: 2000 to 2009
family therapy has spread to Europe, Asia, Africa, Australia and South America
International Family Therapy Association founded in 1987
professional associations continue to grow, providing services, educational opportunities, and publications
licensure has grown to all 50 states
marriage and family therapists recognized as one of five core mental health providers (along with psychiatrists, psychologists, social workers, and psychiatric nurses)
Accreditation of family therapists
two associations accredit marriage and family training programs
Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)
Council for Accreditation of Counseling and Related Educational Programs (CACREP)
Developing culturally effective family-based research

increased research on the effectiveness of family therapy with different cultural groups
continued development of marriage and family therapy in regard to new narratives and approaches to working with couples and families
health care reform

Family therapy: 2010 to the present
Social conditions continue to change, requiring marriage and family therapists to formulate new and more socially relevant ways to work with couples and families
Professional associations such as the AAMFT and the IAMFC rely heavily on technology to disseminate information
Online therapy is becoming more popular and prominent
The AAMFT and IAMFC updated their respective codes of ethics in 2012 to keep pace with the times
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was published in 2013 and continues to pose challenges for family therapists’ treatment of couples and families and reimbursement for their work
The Supreme Court of the United States rendered two important decisions in 2013 with ramifications for marriage and family therapists, one related to the legal definition of “spouse,” and, a second lifted the ban on same-sex marriage in California

Key Terms

Basic Family Therapy Skills Project a project that began in 1987 which focuses on determining, defining, and testing the skills essential for beginning family therapists to master for effective therapy practice.

brief therapy an approach to working with families that has to do more with the clarity about what needs to be changed rather than time. A central principle of brief therapy is that one evaluates which solutions have so far been attempted and then tries new and different solutions to the family’s problem, often the opposite of what has already been attempted.

circular questioning a Milan technique of asking questions that focus attention on family connections and highlight differences among family members. Every question is framed so that it addresses differences in perception about events or relationships by various family members.

dual therapy the name for conjoint couple therapy devised by Carl Whitaker.

family life education the study of family life including developmental and situational factors that affect or change the life of families.

internal family systems model of Richard Schwartz which considers both individual intrapsychic dynamics and family systems.

interpersonal pertaining to matters or relationships between two or more persons.

intrapersonal thoughts, feelings, and processes within a person.

mystification the actions taken by some families to mask what is going on between family members, usually in the form of giving conflicting and contradictory explanations of events.

National Mental Health Act of 1946 legislation that authorized funds for research, demonstration, training, and assistance to states in order to find the most effective methods of prevention, diagnosis, and treatment of mental health disorders.

new epistemology the idea that the general systems approach of Bateson, sometimes referred to as cybernetics, must be incorporated in its truest sense into family therapy with an emphasis on “second-order cybernetics” (i.e., the cybernetics of cybernetics). Basically, such a view stresses the impact of the family therapist’s inclusion and participation in family systems.

ontology a view or perception of the world.

psychoeducation a strategy that involves educational methods such as reading books, attending workshops, listening to audiovisual material and interactive discussions.

reflecting team approach an approach where clinical observers of a therapeutic session come out from behind a one-way mirror observing room to discuss with the therapist and client couple/family their impressions.

schism the division of the family into two antagonistic and competing groups.

second-order cybernetics the cybernetics of cybernetics, which stresses the impact of the family therapist’s inclusion and participation in family systems.

skew (marital skew) a dysfunctional marriage in which one partner dominates the other.

social constructionism a philosophy that states experiences are a function of how one thinks about them and the language one uses within a specific culture. From this perspecitve all knowledge is time- and culture-bound. It challenges the idea that there is objective knowledge and absolute truth. Narrative and solution-focused therapy are based on social constructionism. system a set of elements standing in interaction. Each element in the system is affected by whatever happens to any other element. Thus, the system is only as strong as its weakest part. Likewise, the system is greater than the sum of its parts.

systems theory a theory, sometimes known as general systems theory, that focuses on the interconnectedness of elements within all living organisms, including the family. It is based on the work of Ludwig von Bertalanffy.

therapeutic conversations model a postmodern approach where the family therapist relates to the couple or family in a more egaliarian partnership

undifferentiated family ego mass according to Bowen, an emotional “stuck togetherness,” or fusion, within a family.

Classroom Discussion

1. Freud and others believed that the family is often the source of difficulties and, as a result, the patient should be treated separately from the family to avoid contamination. Family therapy, on the other hand involves family members in the treatment process and brings the action into the room rather than just talking about problems. If you were a member of a professional panel discussion of individual and family therapies, what rationale would you give for the value of family therapy?

2. Client satisfaction rates are claimed to be as high as 97% for marriage and family therapy clients. What do you think accounts for this high rate of satisfaction?

3. Like families themselves, the field of family therapy has changed markedly over the past few decades. Early approaches emphasized giving directives and therapists being “in charge” during treatment. In the 1990’s, social constructivist models emphasized individual rather than absolute truths, and a more egalitarian therapist-client relationship. Discuss the merits of the ‘therapist as leader’ versus the ‘therapist as collaborator’ and explain how these two very different approaches might peacefully co-exist.

Multiple Choice Questions

Which of the following contributed to the development and growth of family therapy?
1. The launching of Sputnik by the Russians.
2. The establishment of career guidance programs.
3. The initial establishment of marriage counseling
4. The establishment in the 1930s of all male boarding schools
Which of the following groups, in the 1920s and 1930s, worked with families from an educational perspective to help them to better understand the dynamics of their family situation?
1. Family Life Specialists
2. Family Counselors
3. Marriage Counselors
4. County Home Extension Agents
Which one of these individuals is responsible for forming the American Association of Marriage Counselors (AAMC)?
1. Ernest Groves
2. Ludwig Von Bertanlanffy
3. Paul Popenoe
4. Abraham Stone
The systems theory developed by Bertanlanffy (1968) had less reliance on _____ and more emphasis on _____.
1. family therapists; paraprofessionals
2. circular causality; linear causality
3. individual parts; societal influence
4. linear causality; circular causality
Jack, a family therapist in the 1960’s, emphasizes the importance of self-esteem, compassion, and congruent expression of feelings. Whose model of family therapy is Jack likely following?
1. Virginia Satir
2. Evelyn Duvall
3. Salvador Minuchin
4. Jay Haley
A type of questioning developed by the Milan Associates, emphasized asking questions that highlighted differences among family members. This type of questioning is called:
1. linear questioning
2. triadic questioning
3. open ended questioning
4. circular questioning
A person who receives a message to “act boldly and be careful” is receiving which type of communication, according to Bateson et al., 1956)?
1. Paradoxical intention
2. Double-bind
3. Circular communication
4. Cognitive dissonance
Which one of the following therapists wrote on conjoint couple therapy and broke with traditional psychotherapy of the time by including spouses and children in therapy?
1. Virginia Satir
2. Jay Haley
3. Carl Whitaker
4. Murray Bowen
Family therapy focuses on the _____ rather than the _____, which creates new and unique ways of resolving problems.
1. intrapersonal; interpersonal
2. physical; emotional
3. individual; system
4. system; individual
In which theory of family therapy is it proposed that human suffering is embedded within a biopsychosocial-cultural framework?
1. Contextual Therapy
2. Strategic Therapy
3. Biopsychosocial Family Therapy
4. Structural Family Therapy
Which of the following refers to asking a third family member how two other members of a family relate?
1. Paradoxical intentions
2. Circular questioning
3. Triadic questioning
4. Bracketing
James gives conflicting explanations of events to mask what is really going on between family members. According to Laing (1965), James behavior can be described as ____________________.
1. Paradoxical intention
2. Scapegoating
3. Enabling
4. Mystification
Which of the following is a body of ideas about gender hierarchy and its impact rather than a specific model of therapy?
1. Filial therapy
2. Strategic Family Therapy
3. Feminist Family Therapy
4. Relational Cultural Family Therapy
Which of the following was a major goal of the Women’s Project in Family Therapy?
1. To bring awareness to the absence of gender in the formation of systems theory
2. To advocate that AAMFT affiliated therapists use feminist family therapy as their main theoretical lens
3. To advocate for greater female representation in leadership roles in AAMFT
4. All of the following were major goals of the Women’s Project.
Which of the following organizations is a division of the American Counseling Association?
1. Division 43
2. AAMFT
3. Association for Marriage and Family Counselors
4. International Association of Marriage and Family Counselors
Which of the following therapies focuses on intensive family therapy along with community-based support for working with juvenile offenders with serious antisocial behaviors?
1. Adlerian Family Therapy
2. Structural Family Therapy
3. Multisystemic Therapy
4. Feminist Family Therapy
Which of the following is a democratic and collaborative model of working with couples and families, in which clinical observers of a therapeutic session come out from behind a one-way-mirror observing room to interact with the therapist and couple/family?
1. Technology-Assisted Family Therapy
2. The Reflecting Team Approach
3. Ecological Family Counseling
4. Multisystemic Therapy
This approach, developed by Carol Anderson (1988), is used with families that have a member with schizophrenia. Attention is given to teaching family members about multiple aspects of mental illness in a day-long survival skills workshop.
1. Therapeutic conversations model
2. Reflecting Team Approach
3. Psycheducational Model
4. Internal Family Systems Model
Which of the following is a philosophy that states that our experiences are a function of how we think about them instead of objective entities?
1. Applied Berkelian Theory
2. Social Constructivism
3. Biocentrism
4. Systems Theory
In which court ruling did the Supreme court rule that section 3 of the Defense of Marriage Act (DOMA) was unconstitutional under the Due Process Clause of the Fifth Amendment?
1. United States v. Windsor
2. Hollingsworth v. Perry
3. Tarasoff v. University of California Berkeley
4. Sutherland v. Madison Memorial

Essay Questions

What trends in society do you think will influence the future development of family therapy?
What historical event or development, in your opinion, most impacted family therapy?

Chapter 2

The Theoretical Context of Family Therapy

Chapter Overview

Historical Perspective

Families have played an important part throughout history in the lives of peoples and nations
Families provide deep emotional experiences such as love, devotion, attachment, belonging, fun, and joy
A family also can be a therapeutic environment for its members by listening, sympathizing, assisting, and reassuring each other
Over time, families have been shaped by social, cultural, economic, and governmental changes

Family Definitions

Families are systems in which the members interact with one another
Family members influence each other and, in turn, are influenced by each other
Because of this mutual interaction, a family is greater than the sum of its parts
The interrelatedness of the family is known as cybernetics
Definitions of what a family is and how it is structured vary across cultures and are constantly changing and evolving
Families are both universal and unique, each family having its own set of rules, sequences, subsystems, feedback loops, hierarchy, and organization
Common family types in American society include nuclear, single parent, and blended, with variations of these three family forms described as dual career, child free, special needs children, gay/lesbian, aging, multigenerational, grandparent headed, and military
The family one grew up in is known as one’s family-of-origin

Individual and Family Development

It is useful to study families from a developmental perspective, (i.e., the predictable changes that occur in individuals and families over time)
The 'life course' refers to different time dimensions such as individual time (the time from birth to death), social time (important social events such as marriage, parenthood, and retirement), and historical time (the era and culture in which one lives)
The term 'life cycle' is used to describe the continuous development of people over time
Individuals and families experience predictable events and developmental crises (changes) which are often sequential
Life cycle stages require some level of success at each stage before proceeding to the next stage. There are times of predictable developmental crises (times of turmoil and opportunity) in each stage.
Erik Erikson, a pioneer in the area of human growth and development, described human life in terms of stages or sequential developmental occurrences. He developed an influential eight stage model of individual development. The first five stages focus on individual skill and identity development, the last three are more interpersonally based
Evelyn Duvall first proposed a family life cycle model based on the intact, middle class nuclear family in 1956. This model has lost influence due to the decrease in number and percentage of nuclear families in the United States
In 1999, Carter and McGoldrick proposed a six-stage family life cycle model of the intact middle class nuclear family that begins with the unattached adult and continues through retirement
Each stage in this model requires key adjustments, tasks, and changes for the individuals to survive and thrive. There is often intergenerational ambivalence in families as children, especially young adults, move to more independence and yet need assistance

Stage 1 Single Young Adults: Leaving Home

the numbers of single young adults is increasing
traditional family oriented activities are being reshaped to accommodate singles
a major task of single young adults is to disconnect and reconnect with one’s family on a different level and to develop a strong identity – a “solid self”
cohabitation (living together without being married) is increasing with positive, negative and neutral aspects to it
singlehood is a viable alternative to marriage; more accepted now than in the past
singles are the second happiest group (married couples being the happiest)
society continues to promote marriage, creating internal and external pressures on singles to marry
singles must establish social networks, find meaning in work or avocations, and live a balanced life to be physically and psychologically healthy
singles typically seek family therapy due to a weak sense of self, inability to separate from their family of origin, and a lack of social skills to establish significant relationships with others

Stage 2 The New Couple: Joining of Families Through Marriage

new couple relationships begin with courtship, in which individuals test their compatibility and tend to idealize the relationship
individuals tend to be most comfortable with others at the same or similar developmental level (e.g., secure men tend to be involved with secure women; anxious women may be attracted to less committed and more disengaged men)
the new couple stage is a period of adjustment and accommodation and requires time, energy, good will, and the ability to compromise
this stage can be quite satisfying for those who are able to resolve differences successfully – they maintain a high level of idealistic distortion about their marriage and spouse,
this stage can result in divorce for those unable to make the necessary adjustments
new couples typically seek family therapy due to the inability to adjust to living as a couple instead of individually, difficulty with relatives (in laws and/or family of origin), inability to develop effective communication and problem solving skills, and differences over whether and when to have children

Stage 3 Families with Young Children

this stage is characterized by dramatic changes in lifestyle which stress a couple's lifestyle and marital relationship,
this stage create new parenting/maternal demands and unbalances the patterns and interactions previously developed – at least temporarily
although marital satisfaction tends to decrease in this stage, strong marital bonds can mediate the stresses associated with children and work issues
families with young children typically seek family therapy due to inability to reorganize and restructure following the arrival of children as well as differences over how to raise and discipline children

Stage 4 Families with Adolescents

this stage is one of the most active and exciting yet it can be very stressful and demanding for many families
couples may be caring for aging parents in addition to adolescent family members they are often squeezed psychologically and physically -- sometimes referred to as the 'sandwich generation'
stressors may include difficulty in setting limits, redefining relationships, and caring and supporting one another; decreasing parental influence and increasing peer influence; generational and gender differences; and maintaining open communication
when adolescents develop 'planful competence' they come to have a realistic understanding of their intellectual, social, and personal responses in their relationships with others
families with adolescents typically seek family therapy due to parent-adolescent conflict, developmental and psychological stress of marital partners who see their dreams 'slipping away,' and the stresses involved with caring for multiple generations of family members as well as for themselves

Stage 5 Launching Children and Moving On

the 'empty nest' describes parents whose children have left home for college, marriage, careers, etc.
this can be a positive time for couples, (e.g., some rediscovering the couple relationship and enjoying new freedoms from responsibility)
this can be a negative time for couples, especially those who have defined themselves primarily as parents and have been heavily focused on their children.
children who leave and then return ('boomerang children') can create tension among family members
families in the launching and moving on stage typically seek family therapy due to a sense of loss of self, the marriage or the child who has left; conflict with the child who is not independent enough; or frustration/anger over the marriage and/or career ambitions

Stage 6 Families in Later Life

within this stage are three groups: the young old (65-74), the old (75-84), and the oldest old (85 and after)
characterized by decline in finances, health, loss of spouse, chronic illness, depression, and helplessness
positive aspects of this stage include interacting with grandchildren, doing what one wants and setting one's own pace, and reflecting on important life activities
families in later life typically seek family therapy due to a lack of meaning or enjoyment in life, concern over the aging process, the lack of quality relationships with family members (for example, children, in-laws, grandchildren)

Unifying Individual and Family Life Cycles

Although outwardly the individual life cycle stages do not appear to have much in common with family life cycle stage, they do share some commonalities
Both share an emphasis on growth and development
Growth is seen as a conscious process that involves a fair amount of risk and courage
Both can be viewed from a systemic theory perspective, which emphasizes the interrelatedness of the entire unit, that a family is greater than just the sum of its parts, and that families have organization, rules, and repetitive patterns
The concept of 'circular causality' is based on the idea that family member's actions influence others and are in turn influenced by others. This differs from 'linear causality' in which actions move in one direction only, with each action causing another
in linear causality, a mother may be seen as the cause of a child's problem
in circular causality, the parent and child interact in a way that results in the problem repeating and intensifying (e.g., the more a parent protects a shy child, the more shy the child becomes, which results in more protection and more shyness, etc.)
Life cycle models are complementary in the development and 'readiness' of persons; they tend to strengthen and prepare people for challenges and work
Life cycle models are competitive in that the needs of individuals often are in competition with the needs of the family and can create tension

Implications of Life Cycles and Family Therapy

The 'fit' between the therapist and the family can influence the outcome of therapy
therapists bringing unresolved issues into their clinical work can create problems
therapists may not have experienced the family's developmental stage, may be currently experiencing the same stage as the family, or may already have been through the family's stage – all of these situations can cause problems
race, gender, ethnicity, class, sibling position, and sexual orientation of the therapist can positively or negatively influence the 'fit' and outcome of therapy.
therapists can improve the 'fit' or match with families by increasing their sensitivity to particular families, obtaining peer or clinical supervision to overcome deficiencies, or receiving continuing education to increase knowledge and skills
- Therapists must be sensitive to cultural differences which require adjustments to life cycle models
- Illness in a family member, either temporary or permanent, disrupts life cycles and can wear down a family's ability to handle the situation or can provide opportunities for growth and cohesion
- Therapists can assess the family's present and prior functioning and assist them to better understand the illness, resolve developmental disruptions, and develop more effective coping methods
- Special-needs children, i.e., those with disabilities, may affect parents/family positively or negatively; regardless expected life cycle of family is affected and therapist must take this matter into consideration
- Poverty and professionalism are economic and social factors that influence families in different ways, with poor families having fewer resources and struggling more with unexpected life events as compared with more affluent professional families

Key Terms

boomerang children adult children who, after being out on their own for awhile, return to live with their parents because of financial problems, unemployment, or an inability or reluctance to grow up

circular causality the idea that actions are part of a causal chain, each influencing and being influenced by the other.

cohabitation effect the phenomenon of lower marital quality, more negative communication, less dedication, and higher rates of divorce for couples who cohabitated before marriage

courage the ability to take calculated risks without knowing the exact consequences

cybernetics a type of systemic interrelatedness governed by rules, sequences, and feedback. The term was introduced as a concept to family therapy by Gregory Bateson. See also new epistemology.

development predictable physical, mental, and social changes over life that occur in relationship to the environment.

empty nest a term that describes couples who have launched their children and are without childrearing responsibilities.

family of origin the family a person was born or adopted into.

homeostasis the tendency to resist change and keep things as they are, in a state of equilibrium.

idealistic distortion viewing one’s marriage and spouse to be better than they actually are

linear causality the concept of cause and effect—that is, forces being seen as moving in one direction, with each action causing another. Linear causality can be seen in, for example, the firing of a gun.

negative feedback loops behaviors that reduce deviation within a system and bring the system back to its former, homeostatic state.

organism a form of life composed of mutually dependent parts and processes standing in mutual interaction.

planful competence when adolescents have a reasonably realistic understanding of their intellectual abilities, social skills, and personal emotional responses in interrelationship with others.

positive feedback loops behaviors that amplify deviation within a system and take the system further away from

homeostasis.

sandwich generation couples who have adolescents and their aging parents to take care of and are squeezed psychologically and physically.

senescence a gradual physical decline of individuals related to age. This decline begins after overall growth stops and varies greatly from individual to individual.

singlehood being single

solid self a Bowenian term for developing a sense of one’s own identity where beliefs and convictions are not simply adaptive to others.

subsystems smaller units of the system as a whole, usually composed of members in a family who because of age or function are logically grouped together, such as parents. They exist to carry out various family tasks.

Classroom Discussion

1. Discuss the pros and cons of the life cycle perspective in assessing and treating couples and families.

2. Pick a particular life cycle stage. Discuss what tasks and challenges you may have encountered and what you and your family may have done to work through them.

3. It is believed that the ‘fit’ between the therapist and the family can influence the outcome of therapy. What are some of the issues that may cause difficulty in this area? What factors may be assets in this area?

Multiple Choice Questions

Families may respond to change by using negative feedback loops, which are loops that:
1. promote a return to the status quo
2. promote change
3. promote appreciation for each other
4. accommodate to new situations and challenges
Families may respond to change by using positive feedback loops, which are loops that:
1. promote a return to the status quo
2. promote change
3. promote appreciation for each other
4. accommodate to new situations and challenges
The family life cycle is useful in studying families from a(n) _____ perspective.
1. psychopathological
2. hierarchical
3. developmental
4. empathic
The three time dimensions referred to as the ‘life course’ are:
1. historical, evolutionary, predictable
2. developmental, historical, cultural
3. individual, social, historical
4. horizontal, vertical, transitional
Erik Erikson, a pioneer in the area of human growth and development, developed an eight stage model of individual development. The first five stages focus on individual skill and identity development. The last three stages focus on:
1. interpersonal development
2. cybernetics
3. idealistic distortion
4. hierarchical structure
Family subsystems include all of the following EXCEPT:
1. parents
2. siblings
3. boys/men
4. spouses
A key task of Stage 1, Leaving Home, of Carter and McGoldrick’s life cycle model is:
1. separation from the family of origin
2. developing effective communication skills
3. developing skills in limit setting
4. developing the ability to compromise
In Stage 5, Launching Children and Moving On, families typically seek family therapy due to:
1. the stresses involved with caring for multiple generations
2. a lack of social skills to establish significant relationships with others
3. frustration/anger over the marriage and/or career ambitions
4. lack of meaning or enjoyment in life
During the New Couple stage, a major task for the couple is:
1. developing effective communication and problem solving skills
2. developing independence
3. developing effective social skills
4. all of the above
Circular causality differs from linear causality. In linear causality, _____.
1. each family member’s actions influence others
2. family member’s actions move in one direction only
3. family member’s actions are complementary
4. family member’s actions are interrelated
A relatively recent development is couples who have adolescents and aging parents to take care of, and who feel they are squeezed psychologically and physically. This development is called:
1. planful competence
2. empty nest
3. circular causality
4. sandwich generation
Although at first they seem very different, the individual and family life cycle models share an emphasis on:
1. interpersonal development
2. intrapsychic development
3. pathological development
4. growth and development
Mike, an emerging adult, has developed what Bowen (1978) calls a solid self. Which of the following, therefore, would accurately describe Mike?
1. His beliefs and convictions are deeply rooted in the beliefs and convictions of others.
2. His beliefs and convictions are not adaptive to others, often resulting in emotional dysregulation.
3. He is emotionally mature, which allows him to be aware of and develop his own beliefs and convictions that are not simply adaptations of others’ beliefs and convictions.
4. He is changing in his lifestyle and attitudes, wherein a greater emphasis on individual events is manifest.
Which of the following statements is true regarding family?
1. Family has remained pretty much the same over generations and across cultures.
2. Family is comprised exclusively of individuals who are biologically related.
3. In the United States, families are increasingly being formed through biological means.
4. Definitions of families have changed over generations and across cultures.
Based on your knowledge of the family life cycle, what unique challenges might Bob and Marie face as a new couple with a baby?
1. Adjusting, adapting, and making decisions together, particularly around where to live, how many children to have, parenting styles, and how they will spend their money.
2. Reestablishing the primacy of marriage.
3. Maintaining dignity despite decline.
4. Experiencing the disequilibrium of the boomerang phenomenon
Which of the following is accurate regarding individual and family life cycle stages?
1. Family and individual lifestyles are independent of each other.
2. Family and individual life cycle stages are constantly intertwining.
3. There is some overlap between family and individual life cycles, but they are largely independent of each other.
4. When conflicts or differences between family and individual life cycles arise with clients, therapists should place more emphasis on the family life cycle.
Which of the following describes the term, cybernetics?
1. A theoretical technology that family therapists will use in the future that uses artificial intelligence to map out feedback loops.
2. State of equilibrium in a system.
3. Systems that regulate themselves through means of feedback loops.
4. Communication processes within a system.
Which of the following groups is considered the second happiest group?
1. Singles
2. Newly weds
3. Couples with adolescents
4. Couples who recently launched their children
Which of the following is a practical challenge of a family in the launching children and moving on stage of the family life cycle?
1. Less predictable routines and schedules
2. Financial burdens and a refocus on work
3. Compatibility of interests
4. Balancing needs and expectations of self and partner
In which phase of chronic illness would someone be classified if one were working toward developing a new sense of self and purpose?
1. Crisis
2. Stabilization
3. Resolution
4. Integration

Essay Questions

Discuss the advantages and potential challenges of using the family life cycle to conceptualize family situations.
Describe what systems theory is and why it is important to family therapy.

Chapter 3

Types and Functionality of Families

Chapter Overview

The Family System and Health

Time changes perspectives on the family; what was considered healthy at one time may no longer be seen the same way later
Traditional families were very patriarchal with men being the breadwinners and rule makers and women staying at home to be the bread makers and caregivers
In modern times, roles have changed and so have family forms with nontraditional families outnumbering traditional nuclear families
The most prevalent family forms are the nuclear family, the single-parent family, and the blended family
Among some of the variations on the nuclear, single-parent, and blended families are the dual-career family, child-free family, special-needs-child/children family, gay/lesbian family, aging family, multigenerational family, grandparent-headed family, and military family
Family health fluctuates over the lifespan as families respond to changes or destabilizing events
Healthy families make adjustments to accommodate to new situations and challenges
Based on systems theory, change in any part of a family affect all the other parts of the family
Depending on the situation, families may respond to change by using negative feedback loops (loops that promote a return to the status quo) or positive feedback loops (loops that promote change)
Healthy families strive for a balance between change and stability; too much stability inhibits growth and produces stagnation, too much change results in chaos

Qualities of Healthy Families

Healthy families encourage positive relationships among family members and insure a good give-and-take balance between individual and family needs
Healthy families do not always produce healthy individuals and healthy individuals may not always come from healthy families
Successful families are balanced in many ways and do not operate from extreme positions of cognition or emotion
Healthy families have a strong and healthy marital unit characterized by promotion of individual growth and mutual support and sacrifice
Characteristics of Healthy Families
commitment to the family and its members (e.g., devotion to individual and family growth, family loyalty)
appreciation for each other (e.g., verbal and physical expression, mutual love, respect, and compliments)
willingness to spend time together (e.g., qualitative and quantitative time, positive time, sharing, builds cohesion)
effective communication patterns (e.g., clear and congruent messages sent and received, wide range of communication, conflict resolution through discussion, positive tone)
high degree of religious/spiritual orientation (e.g., helpful in coping, resiliency, finding meaning, and providing a moral foundation, increases marital satisfaction)
ability to deal with crises in a positive manner (e.g., dealing with events and nonevents with appropriate coping strategies, negotiation, humor, respect, and support)
encouragement of individuals (e.g., strengthens weak members, most crucial in life cycle transitions)
clear roles (e.g., clear, appropriate, suitable allocated, mutually agreed upon, integrated, enacted, interchangeable and flexible)
growth-producing structure and development patterns (e.g., absence of intergenerational coalitions and conflictual triangles, clear boundaries, balance of stability and change)

Family Life Stressors

Stress is a normal part of family life
Vertical stressors are historical and come from previous family history and experience, for example, family attitudes, expectations, secrets, and legacies
Horizontal stressors are related to current events, are developmental and continually unfolding, and may be predictable or unpredictable
Expected life stressors may be developmental (life cycle related), situational (interpersonal), or historical (related to family life history)
Common stressors that are developmental and situational include:
economics and finances
children’s behaviors
insufficient couple time
communicating with children
insufficient personal time
insufficient family play time
Unexpected life stressors include events which occur “off schedule” or not at all. Family adaptability may be related to environment fit (e.g., economic and support factors)
Common unexpected life stressors include
happenstance or random, chance life changes
physical/psychological trauma
success and failure
gaining or losing a family member

Family Structure and Functionality

Family structure influences the ability to handle stressors
Three common family structures:
- symmetrical/complementary
- symmetrical interaction is based on similarity of behavior, i.e., either partner might do the work; it can result in completion between spouses
- complementary interaction is defined more rigidly and maximizes differences in family roles, for example, traditional gender roles
- parallel relationships are a combination of symmetrical and complementary interaction as appropriate and can produce optimum family and couple functioning
- centripetal/centrifugal
centripetal families focus on family closeness, get their needs met primarily through the family, and may produce children who are at their worse family dependent, antisocial, irresponsible, and egocentric
centrifugal families are more disengaged, get their needs met primarily outside of the family, and may produce children who at their worse become socially isolated, disorganized, or withdrawn
extremes of either style are like to result in poor family functioning
at different times both styles are appropriate, e.g., centripetal structure at the birth of a baby; centrifugal structure at the launching of children
cohesion/adaptability
- cohesion, or emotional bonding, can be measured on four levels from low to high: (1) disengaged, (2) separated, (3) connected, (4) enmeshed
- adaptability, or the ability to be flexible and change, can be measured on four levels from low to high: (1) rigid, (2) structured, (3) flexible, (4) chaotic
- the relationship between cohesion and adaptability is curvilinear
- dysfunctional families tend to be either very high or very low on these dimensions, while healthy families tend to be more balanced
- life cycle stage and culture influence these two dimensions and must be considered in assessing families

Coping Strategies in Families

In coping with stress, useful family characteristics include the following:
ability to identify the stressor
ability to view the situation as a family problem, rather than a problem of one member
solution-oriented approach rather than blame-oriented
tolerance for other family members
clear expression of commitment to and affection for other family members
open and clear communication among members
evidence of high family cohesion
evidence of considerable role flexibility
appropriate utilization of resources inside and outside the family
lack of physical violence
lack of substance abuse
Other effective coping strategies include:
recognizing that stress may be positive and lead to change
realizing that stress is usually temporary
focusing on working together to find solutions
realizing that stress is a normal part of life
changing the rules to deal with stress and celebrating victories over events that led to stress
ABCX Model (also referred to as the “check mark diagram”) of adjustment to a crisis
"A" is the stressor event
"B" is the resources available at the family's disposal
"C" is the meaning or significance of the event for the family
"X" is the combined effect of these factors (i.e., the crisis itself)
in this model, the same event may be handled differently by different families
Double ABCX Model of adjustment to a crisis
expands on the ABCX Model by focusing on family interactions between situations and on family resolutions over time.
incorporates the 'pile up of demands' as a variable in how families are able to respond to stressors
An inability to adjust to change can result in families trying the same solutions over and over, thus intensifying nonproductive behaviors and exacerbating the symptomatic behavior
There are two levels of change:
first-order change is characterized by superficial or incremental change
second-order change results in the introduction of new rules and behaviors into existing behavioral patterns; it is metachange

Implications of Health in Working with Families

Studying healthy families is a complex process
Research on healthy families benefits family therapists in the following ways
appreciation for the multidimensionality of families and the mutual influence of family members
identifies areas of health and strength in all families, not just pathology
highlights the developmental nature of both health and pathology in families
increased awareness that healthy families have deficits and dysfunctional families have strengths
awareness of potential stressors helps family therapists prepare families through education

Key Terms

ABCX Model of a crisis in this model “A” represents the stressor event that happens to the family, “B” represents the resources at the family’s disposal, and “C” represents the meaning or interpretation the family attaches to the experience. “X” is the combined effect of these factors (i.e., the crisis itself). This model highlights that the same type of event may be handled differently by different families.

boundaries the physical and psychological factors that separate people from one another and organize them.

centrifugal literally, directed away from a center. It describes how people move away from their family (i.e., family disengagement).

centripetal literally, directed toward a center. It describes a tendency to move toward family closeness.

check mark diagram in the ABCX model of a crisis, the process that a family goes through in adjusting to situations, i. e., it initially tumbles down like the slope of a check mark and then after reaching bottom reestablishes itself like the upslope of a checkmark from anywhere below, the same, or above where it was in the beginning.

complementary relationship relationships based on family member roles or characteristics that are specifically different from each other (e.g., dominant versus submissive, logical versus emotional). If a member fails to fulfill his or her role, such as be a decision maker or a nurturer, other members of the family are adversely affected.

conflictual triangles two individuals, such as a mother and father arguing over and interacting with another, such as a rebellious son, instead of attending to their relationship.

developmental stressors stressful events that are predictable and sequential, such as aging.

DINK an acronym meaning dual income, no kids.

Double ABCX model a model for dealing with crises that builds on the ABCX model but focuses on family resolutions over time rather than in regard to a single happening.

dual-career families those families in which both marital partners are engaged in work that is developmental in sequence and to which they have a high commitment.

family adaptability the ability of a family to be flexible and change.

family cohesion emotional bonding within a family.

family development and environmental fit a concept that states that some environments are conducive to helping families develop and resolve crises, and others are not.

first-order change the process whereby a family that is unable to adjust to new circumstances often repetitiously tries the same solutions or intensifies nonproductive behaviors, thus assuring that the basic organization of the family does not change.

happenstance an unpredictable event, a chance circumstance.

health an interactive process associated with positive relationships and outcomes.

horizontal stressors stressful events related to the present, some of which are developmental, such as life cycle transitions, and others of which are unpredictable, such as accidents.

intergenerational coalitions members from different generations, such as a mother and daughter, colluding as a team.

life cycle transitions predictable movement from one stage of life to another, such as going from being married to being married with children.

metachange a changing of rules sometimes referred to as a change of change.

nonevent the nonmaterialization of an expected occurrence (e.g., the failure of a couple to have children).

parallel relationships relationships in which both complementary and symmetrical exchanges occur as appropriate.

postgender relationship a symmetrical relationship where each partner is versatile and tries to become competent in doing necessary or needed tasks, e.g., either a man or a woman can work outside the home or take care of children.

Resiliency Model of Family Stress, Adjustment, and Adaptation a model of family adjustment that proposes that a family's capability to meet demands is dynamic and interactional

roles prescribed and repetitive behaviors involving a set of reciprocal activities with other family members or significant others; behaviors family members expect from each other and themselves.

second-order change a qualitatively different way of doing something; a basic change in function and/or structure.

situational stressors stressful events that are unpredictable, such as interpersonal relationships that are emotional.

spillover the extent to which participation in one domain, e.g., work, affects participation in another domain, e.g., the family.

symmetrical relationship a relationship in which each partner tries to gain competence in doing necessary or needed tasks. Members within these units are versatile. For example, either a man or a woman can work outside the home or care for children.

vertical stressors events dealing with family patterns, myths, secrets, and legacies. These are stressors that are historical and that families inherit from previous generations.

Classroom Discussion

1. Just as the world changes constantly, so do families. What do you consider some healthy characteristics of today’s families? What are some unhealthy characteristics?

2. In modern times, nontraditional families outnumber traditional families. What are some nontraditional family types? What special difficulties might they face in today’s culture?

3. When families are unable to adjust to change, they often try the same solutions over and over again without success. What are some examples from your own family, pop culture, movies, television shows, or books that illustrate how this can happen? What might they do differently that might help them become healthier families?

Multiple Choice Questions

Studies reveal that healthy and functional families in virtually all cultures are able to:
adapt to change
set appropriate boundaries
express confidence in themselves and their children
all of the above
Members of healthy families often use humor, soothing comments, or changes of subject to steer difficult family conversations in positive directions. This process of redirecting difficult conversations is known as:
redirection
repair
relating
re-authoring
Horizontal stressors are:
related to historical events
related to current events
related to previous family history
both A and C
Symmetrical interaction is based on:
rigidity and maximizing differences
family closeness and getting needs met inside the family
disengagement
similarity of behavior
Cohesion, or emotional bonding, can be measured on four levels from low to high:
disengaged, separated, connected, enmeshed
separated, disengaged, enmeshed, connected
enmeshed, connected, separated, disengaged
connected, enmeshed, disengaged, separated
In the ABCX Model, the “C” is ___________.
the crisis or stressor event
the combined effect of all factors
the resources available at the family’s disposal
the meaning or interpretation the family attaches to the experience
There are two levels of change, first-order and second-order. First-order change is characterized by:
trying the same behavior over and over
nonevents
superficial change
life cycle transitions
Centrifugal families are more _____ than centripetal families.
healthy
disengaged
enmeshed
none of the above
The Double ABCX Model differs from the ABCX Model in some significant ways, including:
awareness of potential stressors
focus on family interactions over time
incorporation of metachange factors
focus on parallel relationships
Useful family characteristics for coping with stress include all the following except:
lack of physical violence
identification of the family member who caused the problem
solution oriented rather than blame oriented
open and clear communication
Which of the following are the three most prevalent family forms in the United States?
nuclear, single parent, and blended
military, nuclear, and grandparent-headed, and multigenerational
Child-free, single parent, and nuclear
Dual-degree, aging, and blended
All of the following are characteristics of healthy families, EXCEPT
Devotion to the welfare of the family and to the growth of each member.
Verbal and physical appreciation
Quantitative and qualitative time spent together
Low volume communication restricted to just a few topics
According to research, a religious/spiritual orientation to life, on average, has which effect on families?
correlates with an overall sense of marital and family health and well-being
leads to restricted and often negative communication among family members
reduces the likelihood that a family would cope with challenges that arise
affects commitment, in that religious/spiritual families tend to be more committed to their religious faith or spiritual practice than they are to each other

Mary, a 15-year-old girl, recently learned that she is pregnant, which is causing a great deal of stress for her and her family. Which kind of stressor would this be considered?
vertical stressor
horizontal stressor
parallel stressor
moral stressor
Which of the following refers to all the random, chance circumstances of life, some fortunate and others not?
Locus of control
Locus of responsibility
Vertical stressors
Happenstance
The Smith family has very defined and fairly rigid family member roles. Max, the husband, is very dominant and, his wife, Jan, is submissive. Based on this information, which relationship best describes the Smith family?
Symmetrical
Complementary
Cohesive
Adaptable
The Jones family, after a few months of intensive therapy, have changed the rules and behaviors by which their family is governed and how individual members of the family interact. What kind of change did the Jones family experience?
First-order change
Second-order change
Unrealistic and unethical change
Realistic and positive change
Which of the following is accurate about balanced families in terms of cohesion and adaptability?
They are enmeshed and rigid.
They are chaotic and disengaged
They are connected and rigid
They are flexible and connected.
Which of the following is true regarding parallel relationships?
Both complementary and symmetrical exchanges occur as appropriate.
Both centripetal and centrifugal engagement occur simultaneously.
They are flexible and connected.
They are directed more toward the parallel center of the system as opposed to the outer feedback loops.
Jim is socially isolated and disorganized. He recently ran away from home after experiencing a great deal of neglect and rejection from his parents. Based on this information, which of the following statements is most likely regarding Jim’s family?
Jim likely comes from a family in which parallel relationships are present.
Jim likely comes from a family in which flexibility and connectedness is manifest.
Jim likely comes from a family in which centrifugal forces are dominant.
Jim likely comes from a family in which centripetal forces are dominant.

Essay Questions

Give two examples of both first-order and second-order change in a family.
Describe three or four reasons that family therapists should study the characteristics of healthy families.

Chapter 4

Working with Single-Parent and Blended Families

Chapter Overview

Single-parent and blended families are common family types in the US
Single-parent families may over time become blended families because of remarriage
Single-parent families and blended families face some similar issues, including adjustment to new roles and new rules, establishment and maintenance of healthy boundaries, and adaptation to changes in daily routines

Single-Parent Families

Single-parent families are headed by a mother or father, a sole parent, responsible for taking care of herself or himself and a child or children (Walsh, 1991)
Single-parent families are created as a result of

divorce
death
abandonment,
unwed pregnancy
adoption
temporary circumstances (e.g., military deployment)

Historically single-parent families were created by death or desertion of a spouse
In the 1950s, families created by divorce started to exceed those created by death
In the 1970s, the decision of many unmarried women to bear and raise children by themselves increased
In 2010, there were approximately 11.7 million single parents living with their children (29.5% of US households with children)

Types of Single-Parent Families

Single parenthood as a result of divorce

two subunits are formed (except in some cases of joint custody)
- custodial parent, with whom the child resides and his or her interactions with the ex-spouse and child(ren)
  - stressors include rebuilding financial resources and social networks
  - benefits include a renewed sense of confidence in oneself
noncustodial parent, and his or her relationships with the ex-spouse and child(ren)
- - stressors include finding ways to stay involved with one’s children as a parent
  - rebuilding of social networks
  - benefits include devising creative problem-solving methods
  - gaining renewed self-confidence
both parents have the same rights, unless a court order specifies differently

Single parenthood as a result of death

reestablishing one’s life and restructuring of the family are major tasks
three stages
- mourning stage – helps with release of positive and negative feelings and emotions; “death ends a life, not a relationship”
- readjustment stage – learning to do new tasks, dropping old tasks, reassigning duties to other family members
- renewal and accomplishment stage – focus on finding and engaging in new growth opportunities

Single parenthood by choice

characterized by choice and intentionality
actions include
- conceiving a child out of wedlock
- carrying a child to term after accidentally becoming pregnant out of wedlock
- adopting a child as a single adult
parent has time to prepare before the child arrives
clear from the beginning that there will usually be no outside support

Single parenthood as a result of temporary circumstances

change that is usually the result of uncontrollable circumstances (e.g., job change, deployment in the military)
usually involves one parent making an immediate move while the other parent remains behind
suddenness and seriousness of the change increases stress levels

Dynamics Associated with the Formation of Single-Parent Families

Dynamics of single-parent families formed through divorce

top three reasons for divorce are social, personal, and relationship issues
social issues
- new technologies
- more alternatives
- less stability
- greater opportunities for frustration, fulfillment, and alienation
- changing of women’s roles
- weakening of alliance of men and their work
- increased acceptance of options, transitions, and a new openness to mores and laws
- divorce is more acceptable today
personal issues
- people marry at different levels of psychological maturity
- people marry with different expectations
- personality conflicts may doom marriages
- some marriages may be best served when the relationship is dissolved
interpersonal issues
- marriages dissolve when couples perceive the costs as exceeding the benefits
- couples frequently do not seek help or seek it too late
common issues following divorce or separation
- resolution of the loss of the marriage
- acceptance of new roles and responsibilities
- renegotiation and redefinement of relationships with family and friends
- establishment of a satisfactory arrangement with one’s ex-spouse
- significant decrease in income
- society as a whole still subtly disapproves and stigmatizes those who divorce

Dynamics of single-parent families formed through death

death is a shock even when expected, important to appropriately grieve
family members should talk to one another and with others
releasing feelings assists family members to see the deceased person as mortal instead of ‘superhuman’

Dynamics of single-parent families formed through choice
- a large and rapidly growing segment of the population
- cuts across racial, social, and economic divisions
- three major factors influencing this trend
- historical tradition
- in maternally oriented subcultures, many children have been raised by single parent mothers and are inclined to avoid marriage and follow the same patterns they grew up in
- racism, ignorance, and socioeconomic crises contribute to this pattern
- such patterns or cycles can be difficult to break
- change and acceptance by society
- stigmas and taboos have been broken down
- traditional norms and patterns have eroded
- choice
- includes women who are well educated and older
- dramatization in books, movies, and television
- it is more socially acceptable for single women to adopt babies
- women who adopt can pick the time when they wish to become a parent
- women who adopt tend to be affluent, not encumbered by a marital relationship, and can provide more nurturance and time to the child(ren)
Dynamics of single-parent families formed through temporary circumstances
- the parent left in charge may be overloaded with extra duties and responsibilities with no additional resources
- the parent must prioritize tasks and decide what can be postponed and/or dropped
- can be a period of disorganization and stress
- the time period for functioning in this way is time-limited

Strengths and Challenges Connected with Single-Parent Families

Strengths of single-parent families
- tendency to be more democratic than most family types
- informal style of relating
- the needs of all parties are usually considered in decision making
- limited resources may result in role flexibility in household tasks regarding which members perform which tasks
- children often learn how to take responsibility for their actions at an early age
- children learn essential skills, such as find a bargain or saving money, faster than most children
- increase in creativity in locating and utilizing needed materials for their overall well-being
- survival skills are developed through being frugal as well as innovative
Challenges of single-parent families

defining and refining boundaries and roles
- problem areas include boundary disputes between former spouses, absent spouses, and between children and their custodial parent or joint custody parents
- boundary issues with former spouses may focus on everything from visitation to sexuality
democratic nature of single-parent families may blur parent and child roles, resulting in chaotic and confusing interactions
- children more than twice as likely to have emotional and behavior problems than children in intact families
- role flexibility may add stress and work resulting in fatigue and burnout
academic difficulties are common for the first 18 months after a divorce
- children of divorced parents are less educated than others their age and are less likely to graduate from high school than those from intact families
- the academic gap between children in single-parent families of divorce and those in two-parent families may be linked to the additional resources that are often available to children in two-parent families
- difficulty establishing a clear and strong identity and relating to the opposite gender
- children of divorce leave home earlier than others
- children of divorce are far more likely to cohabit before they marry
- children of divorce more likely to divorce
- children of divorce may not experience life to the fullest
- children of divorce may come to resent growing up so fast and may consciously or unconsciously display less maturity
single-parent families are financially less well off than other family forms
six times more likely to be poor than are nuclear families
frequently lack child support
50% of children living in single parent families live below the poverty line
emotional issues
common emotions are helplessness, hopelessness, frustration, despair, guilt, depression, and ambivalence
unresolved issues with a significant other
lack of ready access to the needed person
over time, feelings may increase and stress intensify
unresolved emotions keep the person ‘hooked’ emotionally to historical times and situations
usually takes 2 or more years for a single parent family to resolve their emotions and to form into a functional unit

Approaches for Working with Single-Parent Families

Preventative approaches
- premarital counseling results in couples who are more likely to seek marriage therapy more often, had lower levels of stress, and benefited more from marriage therapy than couple without premarital counseling
- programs that help a spouse after a traumatic separation may be extremely beneficial

Educational and Behavioral Approaches for Treating Single-Parent Families

Various educational and behavioral strategies can help strengthen aspects of single-parent families
- helping family members communicate clearly and frequently
- weekly family conference to talk about concerns, resolve problems and plan for the future
- linking family members to needed sources of social support (e.g., Parents Without Partners)
- assisting families with resolving financial matters so they can best utilize their resources
- educational methods such as reading books and newsletters

Role of the Therapist

Therapist must realize single-parent families, as with all families, are socially, psychologically, and economically unique
Biases and personal prejudices about single-parent families
- therapists must examine and set aside their own biases and personal prejudices about single-parent families
- therapists must resolve their own personal problems (e.g., a divorce) that might involve the issue of a single-parent family
- family therapists must deal directly with people, hierarchies, and circumstances of these families, not myths and stereotypes
- family therapists must assist single-parent families in giving up negative stereotypes of themselves
Emotional volatility
- assist clients to distinguish between emotional divorce issues and legal divorce issues
- assist clients to set aside emotional issues at times in order to make mature and reasonable legal decisions
Accessing inner resources
- assist families to tap into their inner resources and strengths
- encourage families to utilize support groups

Process and Outcome

Single-parent families benefit from family therapy in four major ways

more confidence and competence in themselves. Family members:
rely more on themselves and extended networks of family and friends
function better with greater efficiency
have better knowledge of agencies or support networks
experience fewer behavior problems and less stress
increase their relationship skills, especially between parents and children
clear and functional boundaries
new hierarchies, free of intergenerational enmeshment
parentified child’s role is no longer necessary and can be given up
interactions between the new single parent family and others
ability to make informed decisions about remarriage
ability to examine the pros and cons of remarriage options
single parents can make better decisions
children can work through their feelings before instead of after the marriage
utilization of resources
more use of community resources
better use of their own resources
financial and personal management improvement
reduction of negative feelings from past experiences

Blended Families

Terms for blended families include

stepfamilies
reconstituted families
recoupled families
merged families
patched families
remarried families

Blended families consist of two adults and step-, adoptive, or foster children
Blended families have become a norm in American society
High divorce rates (approx. 50%) have contributed to a large remarriage trend because 3 out or 4 divorced people eventually remarry

Forming Blended Families

Most commonly formed when a person whose previous marriage has ended in death, divorce, or abandonment marries a previously married person or someone who has never married
Common concerns of blended families

establishing a blended family is a complex process
complex kinship networks
ill-defined goals
new patterns of interaction
Carter & McGoldrick 3 stage model with developmental issues

Dealing with the death of a parent

before the twentieth century
one of every two adults died before age 50
less than a third of all marriages lasted more than ten years
50% of children lost a parent before reaching maturity
blending of families and use of kinship networks were common responses
death was ‘real’ and rituals helped with mourning and moving on with life
currently
death is covered up or denied in many families
death occurs in hospitals away from family members
funeral services may have closed caskets
those who have died are described in vague terms (e.g., departed, passed on)
result may be incomplete grief
in blended families, family members may have difficulty accepting a new member who is seen as ‘replacing’ a deceased family member
no established guidelines for couples and their offspring to follow in coming together

Dealing with the divorce of a couple

common reasons include affairs and conflicting role expectations
predictors include a husband’s unwillingness to be influenced by his wife and a wife who starts quarrels ‘harshly’ and with hostility
two thirds of divorces occur in the first ten years of marriage
most vulnerable times for divorce are during the first seven years and after 16 to 24 years of marriage
the birth of a child can also produce distress and disruptions
most people who divorce eventually remarry
ethnic groups experience the consequences of divorce differently
African-Americans couples are more likely to separate and stay separated longer before obtaining a divorce and less likely to remarry once separated
a greater percentage of African-American children (75%) will experience divorce than will European-American children (40%)
contact between nonresidential parents and their children declines over the years
boys are negatively impacted without contact with non-residential fathers, becoming less competent and having more behavioral problems than children in other types of family arrangements

Dynamics Associated With Blended Families

“Blended families are born out of loss and hope”
Blended family members often carry a positive fantasy with them about what family life can be like
Before a remarriage can develop, prior experiences with a former family must be resolved
Without mourning and resolving prior issues, it is difficult to emotionally join a new family
Structural characteristics of blended families include
a biological parent elsewhere
a relationship in the family between an adult (parent) and at least one child that predates the present family structure
at least one child who is a member of more than one household
a parent who is not legally related to at least one child
a couple that begins other than simply as a dyad
a complex extended family network

The structure of most blended initially is a weak couple subsystem, a tightly bonded parent-child alliance, and potential ‘interference’
Blended families are binuclear, that is, two interrelated family households that comprise one family system
Blended families have quasi kin who are part of an extended kin network of blended spouses’ families

Issues within Blended Families

Prominent issues center around

resolving the past
alleviating fears and concerns about stepfamily life
establishing or reestablishing trust
fostering a realistic attitude
becoming emotionally/psychologically attached to others

Finding time to establish the couple relationship

younger children (below the age of 9) bond more easily with stepparents but are more physically demanding on parents than older children
adolescent identity development issues may complicate the bonding process

Romantic and negative feelings must be sorted out in a timely and appropriate way

partners may not have thought through feelings they bring into the relationship until after it is formed
expectations may not be realized
unresolved mourning issues may not be adaptable or open to changes

Integrating new members into a cohesive family unit

stepfamilies are less cohesive, more problematic, and more stressful than first marriage families
stepparent/child and sibling relationships are less warm and intimate than first marriage families
interpersonal connectedness and rapport requires much work
stepfather/stepdaughter interactions, especially with preadolescent children, can be especially troublesome
2 to 5 years may be needed to form in-depth relationships with stepchildren and to establish the primary parent role
Visher and Visher have identified eight tasks for stepfamily identity development

Strengths and Challenges of Blended Families

Strengths of blended families

life experience
common interests or opportunities unavailable in the original family of origin
survival of critical incidents from which they have learned about themselves and others
assists in understanding environments in different and potentially healthy ways
can increase empathy and influence individual and family resilience
kin and quasi-kin networks
help reduce couple and family isolation and frustration
may provide moral support, guidance, or physical comfort
creativity and innovativeness
blended family members can offer new ideas, perceptions, and possibilities for resolution of issues
appreciation and respect for differences
ability to appreciate and respect differences in people and ways of living
mothering and fathering can take many different forms
new habits from stepsiblings may be helpful
making the most of situations
coping successfully with difficult situations strengthens blended families
insights gained can be taught to other families

Challenges of blended families

loss of an important member
non-custodial parents may be physically absent but retain a strong impact on the remaining family members
all members of the family may be affected by one individual’s unresolved personal issues related to loss
establishment of a hierarchy
children can lose status regarding their ordinal position in the family
loss of place and power are exacerbated if the children involved don’t like their new stepsiblings or stepparent
until relationship issues are worked out, families may be vulnerable to disruption and volatile emotional and/or physical outbreaks
boundary difficulties
- the structure of a blended family is less clear than biological families
- boundary ambiguity may result in loyalty conflicts and feelings of guilt about belonging to two households
- boundary issues include
- membership (Who are the real members of the family?)
- space (What space is mine? Where do I really belong?)
- authority (Who is really in charge? Of discipline? Of money? Of decisions? etc.)
- time (Who gets how much of my time and how much do I get of theirs?)
- boundary problems can create chaos and members are unsure of who and what is involved in making their lives adaptable
- boundary issues are best dealt with in straightforward fashion, including sexuality issues between unrelated siblings or parents and siblings
- boundary issues can and should be discussed and negotiated by family members
resolving feelings
feelings and emotions need to be resolved but are often suppressed, denied, or projected onto others
economic problems
- as a group, blended families are less affluent than all other family types except single parent families
- lack of money adds stress to the family
- unique expenses of child support and/or the cost of maintaining two residences add to financial difficulty
- blending finances can be difficult but are best achieved through:
- re-evaluating insurance needs
- updating financial documents
- creating and sticking to a budget
- rethinking asset allocations
- developing a will or a living will

Approaches for Working with Blended Families

Guidance in retaining old loyalties

blended family members need not give up old loyalties in order to form new ties
families benefit from learning to be inclusive rather than exclusive
therapists may assess how the family is operating and challenge the family to participate in cooperative interactive events

Focus on parental involvement

stepparents need to balance their involvement so there is a balance among all family members
stepparents should spend time before and after their wedding discussing the impact of past relationships on new relationships
family therapists can help stepparents overcome unresolved issues and learn to contribute to the well-being of all family members.

Provide education
- education can help blended families understand differences between blended family and non-blend family systems and provide guidelines for handling typical situations
- books and pamphlets can be effective for all ages
Assist in the creation of family traditions and rituals

help families develop new traditions and rituals
rituals may be beneficial to:
the forming of relationships
the resolution of ambiguous boundaries
the healing of loss
the settling of hierarchy and power struggles
the creating of beliefs
the beginnings of changes

Role of the Therapist

Therapists must be active, flexible and resourceful in the use of different therapeutic modalities, i.e., wear many hats
Decrease confusion, fear, and depression of children who are the focal points of child custody, visitation, or child support disputes
Be well informed about legal processes as well as psychological ones
Knowledge of family jurisprudence can help all family members make better decisions
Work with family members to arrange predictable and mutually satisfactory arrangements between former parents and their child or children
Help stepparents work together to be effective parents
Encourage family members to relinquish personal myths they have carried into the new family relationship
Help family members learn effective communication skills
Provide information about structured programs and reading lists for both adults and children
Provide a forum within the therapeutic setting for mourning the loss of the previous relationships and developing new relationships in the reconstituted family

Process and Outcome

If therapist is successful, families gain the following:

Better understanding of themselves as systems and subsystems
Support for the new parent and sibling subunits, stressing the importance of learning to work, play, and make mistakes together
Development of age and stage appropriate cohesion
Parents present a unified front regarding acceptable and unacceptable behaviors
Increase tolerance for one another and family life events
Decreased projection and distortions
Eliminating the romanticizing or idealizing of those who are now outside the formal structure of the family
Members find their place in the new family
Family environment becomes cohesive, safe, and open to novel ideas
Fostering of new traditions, celebrations, and rituals
Development of a healthy self-concept of themselves as a family
Development of internal strength to deal with external pressures and stereotypes

Key Terms

custodial parent a parent who has primary physical custody of a child.

joint custody an arrangement where both divorced parents assume equal custody of their children.

noncustodial parent a parent who does not have primary physical custody of a child but who has the same rights as a custodial parent unless there is a court order expressively stating otherwise.

parentified child a child who is given privileges and responsibilities that exceed what would be considered developmentally consistent with his or her age. Such a child is often forced to give up childhood and act like a parent, even though lacking the knowledge and skills to do so.

Parents Without Partners a national organization that helps single parents and their children deal with the realities of single-parent family life in educational and experiential ways.

premarital counseling working with a couple to enhance their relationship before they get married.

quasi kin a formerly married person’s ex-spouse, the ex-spouse’s new husband or wife, and his or her blood kin.

Classroom Discussion

1. Marriage and divorce are ‘hot button’ issues for many clients and family therapists alike. What are your personal values and beliefs about marriage and divorce and how might they impact your work with clients?

2. An increasingly popular trend is single parenthood by choice, often through adoption or conceiving a child out of wedlock. What are your thoughts about the propriety, advisability, advantages, and risks of this type of single-parent family?

3. It is said that “blended families are born out of loss and hope.” Explain what is meant by this statement.

4. Family therapists who work with blended families are well advised to be knowledgeable about legal processes as well as family processes. What are some of the legal processes with which you should be familiar?

5. An important element in the establishment of a healthy blended family unit is the creation of new traditions, celebrations, and rituals. Compare with a partner some of the traditions from each of your families of origin (e.g., holidays, birthdays, family vacations, etc.) and create some new ones that respect and honor your past but represent something for the present and future.

Multiple Choice Questions

In the _____, families created by divorce began to exceed those created by death.
1940s
1950s
1960s
1970s
A large and rapidly growing segment of the population is
single-parent families formed through divorce
single-parent families formed through death
single-parent families formed through abandonment
single-parent families formed through choice
Healthy adjustment of children is strongly correlated with
pre-divorce/death levels of family functioning
mental and emotional anguish
taking sides
premarital counseling
Single-parent families tend to be more _____ than most family types.
autocratic
democratic
rigid
formal
Which of the following is not a recommended educational or behavioral strategy that can help strengthen aspects of single-parent families?
helping family members maintain negative communication patterns
encouraging weekly family conferences to talk about concerns, resolve problems and plan for the

future

linking family members to needed sources of social support (e.g., Parents Without Partners)
suggesting educational methods such as reading books and newsletters
Children of divorce are _______________ to divorce than others.
equally likely
more likely
less likely
no studies have been done on this subject
To help kids through the divorce process, it can be helpful to:
define and refine clear boundaries and roles
have diffuse boundaries and roles
have a more formal style of relating
have both parents tell the children about the divorce and let the children decide who’s right and who’s wrong
A major challenge for children in blended families is:
identifying common interests among new step siblings
establishing a new identity
losing one’s ordinal position from a previous family experience
creativity and innovativeness
Establishing a blended family
is a complex process
is a relatively short process (i.e., 1 to 2 years)
is easier than establishing a family in a first marriage
should be based on established guidelines to follow in coming together
The structure of most blended families initially includes
clear romantic and negative feelings
a weak couple subsystem
a unified parental subsystem
clear boundaries
A formerly married person’s ex-spouse, the ex-spouse’s new husband or wife, and his or her blood kin are called ______.
kin once removed
new kin
new relatives
quasi kin
In working with blended families, therapists should
be passive
be active
be legal advisors
be predictable
An important step in developing new relationships in blended families is
giving up old loyalties to make space for new ties
setting up closed systems to maximize internal family strengths
encouraging projection
mourning the loss of previous relationships
_____ can help blended families understand the differences between blended family and non-blended family systems and provide guidelines for handling typical situations.
education
choreography
genograms
projection
Questions such as “Who are the real members of my family?” “What space is mine?” or “Where do I really belong?” are examples of what kind of challenges in blended families?
economic problems
resolution of feelings
boundary difficulties
establishment of a hierarchy
John, an African-American teenager, takes on many of the roles of an adult, even though he is only 12-years-old. According to research, which of the following would apply to John?
John may experience depressive symptoms and be more likely to become dependent on alcohol.
John will be less likely to experience trauma and adversity.
As an African American, John will likely experience positive psychological benefits from parentification.
John’s will likely be more securely attached to others as a result of parentification.
Which of the following is not considered a strength of a single-parent family?
They are more democratic.
The children mature and take responsibility earlier.
They have unclear and undefined boundaries and roles.
They are creative in locating needed resources.
All of the following are true regarding successful outcomes of therapy for single-parent families, EXEPT:
The single-parent family becomes a blended family.
The family manifests more competence in dealing with external environment and is more confident interpersonally and intrapersonally.
The family makes better financial and remarriage decisions.
The family utilizes their resources as well as community resources more fully.
Which of the following statements is accurate regarding divorce?
50% of adults have been divorced.
Contrary to popular belief, divorce rarely occurs because of infidelity or incompatibility.
Parenting usually becomes clearer and more defined when divorce occurs.
Divorce does not end family life; rather, it alters its shape.
Manny, a family counselor, is working with a child who is struggling to adjust to his new blended family. Manny suggests that the child read the book, The Boys and Girs Book about Stepfamlies. Which of the following statements is accurate about this technique?
Bibliotherapy is appropriate for children from single-parent families but not for children in blended families.
Bibliotherapy is not a technique that counselors use. It’s much more appropriate for non-therapeutic professionals, such as teachers or librarians.
There are numerous books and resources that can be used in a thereapeutic way to help individuals who are adjusting to a blended family situation.
Bibliotherapy only works with children who can read at a 4^th grade reading level.

Essay Questions

Discuss the strengths and challenges of single-parent families.
Describe positive therapeutic outcomes for blended families.

Chapter 5

Working with Culturally Diverse Families

Chapter Overview

Multiculturalism is a term used to refer to the cultural groups within a region or nation and their needs
Although American society has been diverse since its beginnings, little focus was placed on multiculturalism until the 1970s and 1980s

assumption that conceptual, theoretical, and methodological frameworks already developed would be appropriate for everyone, regardless of color or background
until the 1980s, the non-white population was relatively small in the United States
today, non-white racial and ethnic groups are growing rapidly and intercultural couples are becoming more common
1 in 15 marriages in the United States in 2005 were mixed race or ethnicity, a 65% increase from 1990

Interethnic, interfaith, and interracial couples experience challenges both inside and outside the couple and family
Family therapists must be open to diversity and culturally competent to be effective
Cultural competency is sensitivity to factors such as race, gender, ethnicity, socioeconomic status, and sexual orientation and the ability to respond appropriately in a therapeutic manner to persons with a different cultural background than their own
Therapists who are not culturally competent risk undervaluing, misunderstanding, and/or pathologizing client behaviors
Although cultural groups share similarities, stereotyping groups according to cultures should be avoided; within group differences are greater than outside differences in cultures

What is Culture?

Culture is the customary beliefs, social forms, and material traits of a racial, religious, or social group

culture include diverse groups of people who may differ in regard to race, religion, or social status but who identify themselves collectively in a certain way
cultures operate on many levels, inclusive or exclusive, specific or general
cultural values define behaviors and therefore establish norms for attitudes and behaviors within families

Ethnic groups are large groups of people classed according to common racial, national, tribal, linguistic, or cultural origin or background

ethnicity influences the kinds of messages that people learn, such as patterns for intimacy
ethnic family customs influence a group’s “fit” within an overall culture

Dynamics Associated with Culturally Diverse Families

The ways in which families from different cultural backgrounds view and respond to life events differs from other families

Jewish families often marry within the group, encourage children, value education, and use guilt to shape behavior
Italian families place importance on expressiveness, personal connectedness, enjoyment of food and good times, and traditional sex roles
certain events in the family life cycle represent greater crises for one culture than another
Irish families view death as the most significant life cycle transition and will go to great lengths to not miss a wake or a funeral
Puerto Rican families stress interdependence in their culture and therefore experience death as an especially profound threat to the family’s future and often experience extreme anxiety

Culturally diverse families often experience overt as well as covert criticisms of their patterns of family interaction that may not be universally accepted

women who are treated as inferior by certain families may be taken to task by others
majority culture may ignore or disdain important civic or religious holidays in particular cultural groups

Physical appearance (e.g., skin color, physical features, dress) may lead to subtle and blatant prejudice and discrimination

minority culture families are faced with the task of nurturing and protecting each other in ways unknown to majority culture families

Access to mental health services may be difficult for minority culture families, i.e., institutional barriers

location, formality, advertising of services, clinic operation hours, language used, and lack of culturally diverse practitioners may limit access and utilization of services by culturally diverse families

Economic factors such as exclusion from certain jobs and limited employment opportunities result in many culturally diverse families living in poverty

Issues within Culturally Diverse Families

Family therapists may be at an initial disadvantage in working with culturally diverse families because the field of marriage and family therapy reflects a dominant European American bias
Sensitivity, experience, acceptance, ingenuity, specificity, and intervention are factors that often determine successful treatment
Sensitivity

sensitivity and respect for beliefs and the worldview of the client/family is crucial
‘culturally encapsulated counselors’ tend to treat everyone the same and make mistakes in so doing for they miss diversity

Experience

family therapists can benefit from having life experiences that include cultural diversity
cultural backgrounds of culturally diverse families are often influenced by a family’s experience with the larger society

Acceptance

therapists who cannot openly accept culturally diverse families may exhibit overt or covert prejudice that negatively impacts the therapeutic process
social, behavioral, and economic differences need to be examined to determine whether the therapist and family are a good match
Ho (1987) has developed a model for examining therapist’s values

Ingenuity

effective family therapists utilize natural help-giving networks that exist in most cultural settings
therapists act as consultants to agencies and persons who can best work with certain families
some cultures may respond best to subtlety and indirectness on the part of the family therapist rather than direct confrontation and interpretation

Specificity

because each family is unique, family therapists must assess the strengths and weaknesses of each family and design and implement specific procedures for each
therapy models should be selected and/or modified to address the needs of specific families

Intervention

therapists serve as systematic change agents by intervening on behalf of families in unhealthy and intolerant systems
some systems involve ‘passive insensitivity to diversity’ (i.e., the plight of people outside one’s culture is simply ignored) while others involve ‘active and intentional insensitivity to diversity’ (i.e., fostering active discrimination that is easier to identify)
advocating for culturally diverse families requires courage, persistence, and time

Approaches for Working with Culturally Diverse Families

Culturally diverse families have some commonalities, including the importance of extended family and kinship ties
There are a number of culturally diverse families including the invisible family form Gay/Lesbian (found in most cultures) and six culturally diverse family groups: African Americans, Asian Americans, Hispanic/Latino Americans, Native Americans, Arab Americans, and European Americans

Gay and Lesbian Families

Working with gay and lesbian families

therapists need to begin by examining their own values and feelings regarding this population
therapists need to be aware of internal and external issues associated with being a gay or lesbian couple or family, including cultural and societal homophobia and local, state, and national laws affecting gays and lesbians
extended families may need to be involved in treatment due to the difficulty many families have in accepting the lifestyle and sexual orientation of their kin
treatment planning can be complex due to the variety of gay and lesbian lifestyles and subcultures
a challenge is assisting families to relate positively to themselves, their partners, and society
commitment ambiguity can occur where one partner is not sure about his or her place in the relationship

African American Families

Working with African American families

although utilization rates for individual therapy are high, they are low for family therapy
traditionally, African American families have relied upon extended family networks
men, in particular, have been reluctant to share intimate thoughts and feelings because of socialization patterns that have taught them not to share pain and frustration
trust issues must be resolved between non African American family therapists and African American families
it is helpful to frame family therapy as a form of social support that African Americans can benefit from
psychoeducation, especially with single parent African American women, can be effective
clear understanding of multigenerational family systems in African American communities, especially the importance of respect for elderly family members, is crucial for therapists to understand
therapists must assure families that they can learn how to handle many of their own problems, increase their confidence and competence levels
social and institutional issues may need to be challenged when they act as barriers to improvement and African American families must learn to advocate on their own behalf
presentation of positive role models to African Americans can also make a difference

Asian American Families

Working with Asian American Families

levels of acculturation must be assessed
first-generation families may need assistance in interrelating to other families and societal institutions; problems of social isolation, adjustment difficulties, and language barriers may also be prevalent
role of the therapist with first-generation families may be primarily educational and avocational rather than remedial
established families may need help in resolving intrafamily difficulties such as intergenerational conflicts, role confusion, and couple relationships
an acculturation gap (i.e., different rates of acculturation) between immigrant parents and U.S. raised children often result in misunderstandings, miscommunications, and conflict
because most Asian American families are reluctant to initiate family therapy, therapists can be most effective by doing the following:
orient them and educate them to the value of therapy
establish rapport quickly through the use of compassion and self-disclosure
emphasize specific techniques families can use to improve relationships and resolve problems
racism may disrupt internal family dynamics as well as outside relationships
therapists can assist by addressing societal changes and assessing family skills and values for dealing with prejudice and discrimination
therapists must create a safe and nurturing environment where family members are respected and, without fear, explore relevant problems and concerns
general guidelines for working with Asian American families
assess support available to the family
assess past history of immigration,
establish professional credibility
be problem focused/present focused
be directive in guiding the therapy process
provide positive reframes that encourage the family

Hispanic/Latino American Families

Working with Hispanic/Latino families

family plays a central part in Hispanic/Latino culture
therapists need to develop a basic knowledge about cultural traditions (e.g., traditional rituals, religious festivities, Quinceanos, engagements, weddings, and funerals)
Hispanic/Latino individuals prefer to get to know someone as a person rather than assessing others based on external factors (e.g., occupation, socioeconomic status)
Hispanic/Latinos tend to be physically expressive (e.g., gesturing while they talk)
specific therapeutic considerations
stress related to economic and working conditions can contribute to intrafamily difficulties; therapists can advocate and be a resource in this area
assess for different levels of acculturation and how the pressure to acculturate may contribute to family turmoil, especially as it relates to family loyalty
language factors, especially bilingualism, must be explored
outside resources, such as the Catholic church, may be helpful in providing social, economic, and emotional support
therapist must reinforce the father as being the central figure of the family
therapist must initially accept the role of women as self-sacrificing and victims of other family members and redirect this behavior to assist in getting others to therapy
Hispanic/Latinos expect therapy to be brief, reflecting their experience with physicians

American Indians (AI) and Alaska Natives (AN) Families

Working with AI/AN families
- outsiders do not gain entrance into the family easily
- indirect forms of questioning and open-ended questions work best
- therapists should know and utilize sacred symbols that can be used metaphorically as models for relationships
- admission by therapists that they may make mistakes in treatment because of cultural ignorance is helpful in establishing rapport
- home-based therapy works well by offering essential services to families who would not otherwise receive them
- many AI/AN languages have a visual emphasis (e.g., the verb ‘to learn’ is a combination of the verbs ‘to see’ and ‘to remember’)
- concrete and active behavior, rather than insight is stressed in AI/AN healing
- therapeutic approaches that are directive but open ended are effective

Arab American Families

Working with Arab American Families
- sharp delineation of gender roles
- patriarchal authority patterns
- conservative sexual standards
- emphasis on self-sacrifice for the greater good of the family
- emphasis on honor and shame (i.e., outside help is sought only as a last resort)
- negative fallout, tension, and distrust from September 11, 2001
- clinical recommendations for therapists
be aware of the unique cultural context
be sensitive to issues of family leadership and authority
be aware of the strong influence of the family in decision making
be sensitive to the large role of culture
be aware strengths-based approaches are most effective
be active and balanced so as not to be seen as a rescuer or a threat
- initial interventions should focus on exploring identity, blending Arab and American identities, and replacing either/or decision making
- genograms can be helpful to assess couple/family strengths, both past and present
- although difficult, focusing on couple dynamics can help each spouse find needed support
- helping Arab Americans access religious and other groups can provide support and a sense of community

European Americans

As a group European Americans are sometimes referred to under the category of “White” due to their skin color
White skin is assumed to grant an individual membership into a privileged group
Most people equate White with White Anglo-Saxon Protestant (WASP) ideals
As with other groups, European Americans are a diverse group, coming originally from countries such as Italy, France, Germany, Ireland, Sweden, Hungary, Ireland, and Greece

some groups of European Americans (e.g., Italians, Slavics, and Irish immigrant groups) have experienced racist treatment from other European American groups
WASP values such as rugged individualism, mastery over nature, competitiveness, and Christianity, are not representative of all European Americans
similarities between European American groups and other groups exist, such as being middle-class; many differences too

Working with European Americans

no one approach fits best
different approaches may work best for select cultural groups

Guidelines for Selecting Treatment Approaches in Working with Culturally Diverse Families

Two main approaches

culture-specific model
emphasis on values, beliefs, and orientation of different ethnic cultural groups
basis for most counselor education multicultural courses
focus on memorizing variations among groups may result in information overload and emphasizing stereotyping rather than uniqueness among groups
universal perspective model
a generalist approach
assumption that developed counseling models can be successfully adapted to different cultural groups
focuses on identifying similarities in human processes, regardless of ethnicity or cultural background
may be too general to be of any real use to therapists

General guidelines in selecting interventions

assess whether the family’s difficulties are internal or external
for internal problems, standard approaches may be employed
for external problems, culture specific approaches may be best
determine the family’s degree of acculturation
“Americanized” families may respond to a broader range of interventions than families of new immigrants or only second generation
explore the family’s knowledge of family therapy and their commitment to problem resolution
for families with little knowledge of mental health services or with time pressures, educational and/or direct, brief-theory driven approaches are recommended
for other families, culture specific approaches are recommended
identify what the family has tried before and what they prefer
preference is an important element for establishing rapport and treatment effectiveness

Role of the therapist
- intellectual and emotional exploration of biases and values is essential
  - some majority culture therapists may minimize the impact of societal or cultural expectations on minority families
- culturally skilled family therapists have the following characteristics
- aware and sensitive to their own cultural heritage and to valuing and respecting differences
- comfortable with differences between themselves and their clients
- sensitive to circumstances that may indicate the need to refer a family to another therapist (e.g., personal biases)
- knowledgeable of personal racist attitudes, beliefs, and feelings
- family therapists blend different styles of family therapy with the unique cultural or ethnic values of the family
- family therapists should remain concurrently culturally sensitive and open to themselves and the family
- provide support, when and where appropriate, for the expression of thoughts and emotions
- assist families to acknowledge and celebrate their heritage and marker events, especially those associated with specific life cycle stages
- assist families to be aware of, accept, and adjust to family life stages
- four major investments therapists must make (ESCAPE)
- E – engagement with families and process
- S-C – sensitivity to culture
- A-P – awareness of family potential
- E – knowledge of the environment

Key Terms

acceptance the therapist’s personal and professional comfortableness with a family.

acculturation the modification of a culture as a result of coming into contact with another culture. In many instances, minority cultures incorporate many traditions and mores of majority cultures in attempts to “fit in.”

acculturation gap different rates of acculturation between immigrant parents and U.S.-raised children that complicates the normal generation gap. The results of this gap may result in greater misunderstandings, miscommunications, and eventual conflicts among family members than would otherwise happen.

commitment ambiguity a situation usually in gay and lesbian couple relationships where one partner is not sure about his or her place in the affiliation.

culturally encapsulated counselors professional therapists who treat everyone the same and, in so doing, ignore important differences.

culture the customary beliefs, social forms, and material traits of a racial, religious, or social group.

cultural competency sensitivity to such factors as race, gender, ethnicity, socioeconomic status, and sexual orientation as well as the ability to respond appropriately in a therapeutic manner to persons whose cultural background differs one’s own.

culture-specific model of multicultural counseling a model of counseling that emphasizes the values, beliefs, and orientation of different ethnic cultural groups

ESCAPE an acronym that stands for four major investments therapists must make: (1) engagement with families and process, (2) sensitivity to culture, (3) awareness of families’ potentials, and (4) knowledge of the environment.

Hispanic or Latino a person born in any of the Spanish-speaking countries of the Americas (Latin America), Puerto Rico, or the United States who traces his or her ancestry to either Latin America or to Hispanic people from U.S. territories that were once Spanish or Mexican.

home-based therapy a method of treatment that requires family therapists to spend time with families before attempting to help them.

institutional barrier any hardship that minority populations must endure to receive mental health services, such as the inconvenient location of a clinic, the use of a language not spoken by one’s family, and the lack of diversified practitioners.

intercultural couple individuals who elect to marry outside of their culture

multicultural a term used to refer to the cultural groups within a region or nation.

racism discrimination or prejudice based on race.

systematic change agent the role a therapist takes when he or she tries to intervene on behalf of families in unhealthy and intolerant systems.

universal perspective model of multicultural counseling a model of counseling that assumes that counseling approaches already developed can be applied with minor changes to different cultural groups. Thus, cultural differences are recognized from a family systems perspective.

WASPs white anglo-saxon protestants, often the group associated with the term “White.”

White a term that is sometimes generalized and used to describe any person with white skin who has European ancestory.

worldview the dominant perception or view of a specific group.

Classroom Discussion

1. The two main approaches used in working with culturally diverse families, the culture-specific model and the universal perspective model. Both approaches have strengths and weaknesses. Debate the merits of each and try and identify a ‘hybrid’ that might have greater utility and usefulness in working with culturally diverse families.

2. The Hispanic/Latino population is the nation’s largest growing minority. Hispanic/Latino individuals prefer to get to know someone as a person rather than assessing others based on external factors (e.g., occupation, socioeconomic status). What are some strategies and/or things you would do or say to develop a trusting relationship with a Hispanic/Latino family that respects this cultural preference?

3. Following the events of September 11, 2001, Arab Americans have suffered negative fallout, tension, distrust, and both overt and covert discrimination. In addition, Arab American culture is very different in many ways from North American culture. What are your biases, values, and beliefs about Arab Americans and working with Arab American families? How would/could you address any issues which might limit your effectiveness with this population?

Multiple Choice Questions

Multiculturalism is
1. a term used to refer to distinct cultural groups within a region or nation and their needs.
2. a family, tribe, people, or nation belonging to the same stock
3. the customary beliefs, social forms, and material traits of a racial, religious, or social group
4. the dominant perception or view of a specific group
Culture is
1. a multidimensional concept that encompasses the collective realities of a group of people
2. a family, tribe, people, or nation belonging to the same stock
3. a bidirectional process in which beliefs and values of one group transfer to another group.
4. the transcient perception or view of a specific group
An intercultural couple is working on melding each of their cultures together and celebrating each. This means that they are work on which one of the following?
1. Coexistence
2. Integration
3. Resolution
4. Cultural dominance
Maria tends to see her clients, irrespective of cultural or racial/ethnic background, as the same. Which of the following terms properly describes Maria?
1. systematic change agent
2. WASP
3. culturally encapsulated
4. culturally diverse
All of the following are examples of an external challenge that LGBT individuals face, EXCEPT
1. cultural and social homophobia
2. lack of legal opportunities and rights
3. difficulties in adoption
4. struggles with sense of self
Traditionally, African Americans have relied on _____ for support.
1. an emphasis on social stability and collectivity
2. a collectivistic culture
3. financial stability
4. extended family networks
Although utilization rates for individual therapy are _____ among African Americans, they are _____ for family therapy.
1. high, low
2. low, high
3. about the same for each
4. none of the above
Maki, an Asian American adolescent has adapted to United States culture much quicker than his mother and father. Which of the following terms describes this phenomenon?
1. Cultural adapation
2. Acculturation gap
3. Cultural desensitization
4. Cultural transference
The Chang family, an Asian American family, recently began working with a family therapist at the request of a school social worker. Which of the following statements, based on information in your text, would be an important consideration for the family therapists?
1. Make sure the family is familiar with and educated about therapy.
2. Avoid self-disclosure, as it could be seen as wasting the family’s time.
3. Be careful not to focus on specific techniques or interventions with the family, as it may be interpreted as disrespectful.
4. Assume that the family is familiar with family therapy.
Which of the following is true regarding Latina/o couples and families relative to mental health?
1. Latina/o families and couples experience low rates of mental health issues and, therefore, utilize mental health services sparingly.
2. Latina/o families and couples experience a high rate of mental health issues and, therefore, utilize mental health services at a higher rate than other ethnic/racial minority groups.
3. Latina/o families and couples experience a high rate of mental health issues, but utilize mental health services at a lower rate than other ethnic/racial groups.
4. Latina/o families experience a low rate of mental health issues, but utilize mental health services at a higher rate than other ethnic/racial groups.
Edward, a family therapist, prefers to use short-term theories of family therapy, particularly one that emphasizes structured, child-centered play therapy in which parents are taught to respond to their children on an emotional level. According to this description, Edward is likely practicing which type of therapy?
1. Filial therapy
2. Person-centered therapy
3. Psychodynamic play therapy
4. Marriage and relationship education therapy
Which of the following, based on acculturation research, is accurate?
1. Family members generally acculturate at the same rate.
2. Family members may acculturate at different rates.
3. Adults, due to their more developed prefrontal cortex, tend to acculturate more quickly than their children.
4. Acculturation has little bearing on how a family therapist should conceptualize or treat immigrant families.
Which of the following statements is accurate regarding Asian American families and racism?
1. Racism is something that all ethnic/racial minority groups face, and Asian Americans are not immune. However, due to their model minority status, their experience with racism does not disrupt internal family dynamics.
2. Racism is very uncommon for Asian Americans and, therefore, does not impact their family dynamics.
3. Racism is problematic for Asian American families, similar to other ethnic minority families, and it may disrupt interal family dynamics as well as outside relationships.
4. Although it is very rare for Asian Americans to experience racism, when they do, it tends to disrupt internal family dynamics dramatically.
Dr. Ong works with a number of Latino couples, and she uses an empirically supported, skill-based group program designed to teach couples to build and maintain health relationships. Which of the following techniques, based on this description, is Dr. Ong using?
1. Filial Therapy (FT)
2. Solution-Focused Brief Couples Therapy (SFBCT)
3. Psycho-Educational Rational-Focused Emotional-Cognitive Therapy – For Couples (PERFECT - FC)
4. Marriage and Relationship Education (MRE)
Marsha, a family therapist, is working with an American Indian family. She has read that open-ended questions lead to responses more than closed questions. Which of the following is an example of an open-ended question?
1. How old are you?
2. What would you like to discuss today?
3. Did you come to counseling because you were struggling with your adolescent daughter?
4. Have you thought about yelling less?
In the ESCAPE acronym developed by Boynton (1987), the S stands for
1. Systematic conceptualization of families and processes
2. Sensitivity to culture
3. Symbiosis
4. Synergy
Which of the following is accurate regarding traditional help-seeking behaviors of Arab Americans?
Arab Americans often recognize the importance of mental health services and tend to utilize them frequently.
Arab Americans tend to trust psychologists and social workers more than counselors and marriage and family therapists.
Individuals from Arab cultures usually only seek outside help from so-called helpers or doctors as a last resort.
Once Arab Americans do seek counseling services, they tend to appreciate insight-oriented or person-centered approaches.
“WASP” families, according to the text, are known for their _____________.
high levels of emotional expressivity
collectivistic orientation
homogeneity
tendency to suppress thoughts and feelings.
Which one of the following models emphasizes the values, beliefs, and orientation of different ethnic cultural groups?
culture-specific model of multicultural counseling
universal perspective model
hermeneutic model
ESCAPE
In all forms of family therapy with culturally diverse families, it is essential for family therapists to:
memorize variations among cultural groups
utilize standard approaches
make assumptions in order to generalize treatment among cultural groups
explore personal biases and values

Essay Questions

Describe the similarities and differences between the culture-specific and the universal perspective models of multicultural counseling?
Describe how culturally competent family therapists can use their knowledge of diverse cultural groups to improve their work with culturally diverse families without stereotyping them.

Chapter 6

Ethical, Legal, and Professional Issues in Family Therapy

Chapter Overview

In family therapy, there is a link between selecting treatment approaches and professional issues, such as ethical and legal factors
Knowledge of ethical, legal, and professional issues can prevent clinical or personal actions that result in harm to families
For family therapists to stay healthy, they must abide by ethical codes and legal statutes and practice according to the highest standards possible

Overview of Ethics in Family Therapy

Ethics are moral principles from which individuals and social groups, such as families, determine rules for right conduct
Relationship ethics refer to ethics in a family that are based on the principles of equitability and caring.
equitability – everyone is entitled to have his or her interests and welfare considered in a way that is fair from a multilateral perspective
caring – moral development and principles are centered in the social context of relationships and interdependency
Early family therapy models stressed neutrality, rarely discussed ethical principles with clients, and believed theory and practice were ‘value free’
Modern practitioners understand that all therapeutic decisions are related to values and cannot be ethically neutral
Family therapists may face more ethical conflicts than other types of therapists due to the complexity of relationships and of meeting the needs of multiple individuals within the system

Ethics and Values

Values are a ranking of an ordered set of choices from the most to the least preferable
Values have four domains
personal
family
political/social
ultimate
Effective family therapists closely examine their own values first
ethical genograms help determine how one’s family of origin made tough ethical decisions
examine the values of client families from a systemic view (i.e., how family members’ values affect the family as a whole) and negotiate with the family if values are far apart
explore values associated with theories, processes, and outcomes selected
using therapy as a means to promote personal values is unethical
denying the role of values in selecting treatment approaches and outcomes can lead to clinical errors and possible harm to clients

How Do Values Influence Ethical Practice?

All ethical decision making has, as its core, the values, beliefs, and preferences of individuals and groups
“All values that deal with social rights and obligations inevitably surface in ethical decisions” (Doherty & Boss, 1991, p. 610)
Action-oriented research focuses on finding solutions to problems such as abuse
Family therapists are ethically bound to be honest and open with client families, clearly informing them of biases and values that impact clinical practices and outcomes

Guidelines for Making Ethical Decisions

Family therapists must be aware of professional guidelines for making ethical decisions
Five primary models and resources

Codes of ethics – guidelines developed by professional associations (e.g., AAMFT, IAMFC) to address issues confronting family therapists including:

confidentiality
responsibility to clients
professional competence
integrity
assessment
financial arrangements
research and publications
supervision
public statements
common ethical concerns include
treating the entire family
being current on new family therapy developments
seeing one family member with the others present
sharing values with clients
few specific behavioral guidelines on what to do and how
dual or multiple relationships can be problematic
determining the best course of action from simply reading the code of ethics may be difficult for both beginning and experienced family therapists

Educational resources

case histories relating to ethical dilemmas
User’s Guide to the AAMFT Code of Ethics (AAMFT, 2001)
The Family Journal
ethical decision making process involves the following steps
generate a continuum of alternative actions for the good of the family and to meet professional responsibilities
evaluate and weigh the consequences of each
make a tentative decision and consult with colleagues/supervisors
implement the decision
document the process

Professional consultation
- - consultation is the use of experts in an area to enhance one’s own knowledge and abilities

internal consultation – talking with an expert where one works about an ethical matter
outside consultation – conversations with a professional outside one’s agency or setting
process consultation – conferring with an expert about the ethics or methods one is using with a family
outcome consultation – focuses on the ethics of what the therapist and/or family hopes to accomplish
formal consultation – input received from an expert through an appointment or structured meeting
informal consultation – talking with an expert in the hallways at a professional therapy conference or some less structured way of interacting

Interaction with colleagues and supervisors

provides opportunities for sharing of expertise and wisdom
colleagues may be more accessible than consultants/ed. materials
cost is inexpensive or free
direct supervision by noncolleagues is effective and recommended
family therapy supervision is different from individual therapy supervision
focus on interpersonal as well as intrapersonal issues
videotapes used to critique work
one-way mirrors for live observation and/or supervision
bug-in-the-ear supervision allows live communication with the therapist during sessions

Meta-ethical principles

high level principles that guide ethical decision making
autonomy – the right of individuals to make decisions and choices
nonmaleficence – the avoidance of doing possible harm to a client through one’s actions
beneficence – doing good and promoting the welfare of the client
fidelity – being trustworthy, loyal, and keeping one’s promises
justice – treating people equally

Common Ethical Concerns

Confidentiality is the ethical and legal duty to fulfill a contract or promise to clients that the information revealed during therapy will be protected from unauthorized disclosure
- Confidentiality issues should be conveyed to all family members in a written professional self-disclosure statement
Confidentiality has limitations, including:
if clients may inflict harm on themselves or others
when the mental or physical health of a client(s) is called into question
when child or elder abuse or neglect is suspected
when clients give the therapist written permission to share information (e.g., with another professional)
privileged communication is a client’s legal right that confidences originating in a therapeutic relationship will be safeguarded
avoid talking about cases in public
cell phones, e-mails, and faxes may not be secure
office personnel must understand and abide by confidentiality requirements
client information stored on computers should be password protected
computers should be oriented so that unauthorized persons cannot view the screen
client notes and records must be kept securely locked
Gender issues
gender of therapist and family members influence what issues are addressed in treatment
gender sensitive issues may include
- the balance of power between a husband and wife both financially and physically
- the rules and roles played by members of different genders and how these are rewarded
- what a shift in a family’s way of operating will mean to the functionality of the family as a while
avoid implementing changes in gender-prescribed behaviors solely based on therapist values or beliefs
failure to address emotional abuse or intimidation that is lethal to the life and functioning of the family is irresponsible
Sex between a therapist and a family member
sexual relations between a therapist and client are forbidden in the code of ethics of all family therapy associations
if sexual behavior between a therapist and client is discovered, the person receiving the news should confront the accused professional with the evidence and file a written report to the appropriate association ethics and/or licensure/certification board
ethics and licensure boards have the authority to investigate, receive testimony, make a decision, and determine appropriate consequences
Theoretical techniques
some theoretical approaches are controversial and should be used with discretion
conscious deceit
paradox
neutrality when violence is occurring
Multicultural therapy issues
multicultural competence is necessary to insure therapists do not impose their values on families
three potentially serious ethical errors in working with minority culture families

overemphasize similarities
overemphasize differences
make assumptions that either similarities or difference must be emphasized

‘culturally relevant perspective’ identifies what is culturally significant from the family’s perspective rather than from a prescribed cultural perspective that may not be relevant to a family
Use of the Internet for online therapy
useful to communicate with clients locally and around the world
clients can email questions to a counselor and receive an email response within 24 to 72 hours for a predetermined fee
hearing impaired clients or clients in remote areas can benefit from Internet based counseling
introverted clients may benefit from web based counseling
communication with families or family members in between sessions for guidance, to lower anxiety, or clarify issues
ethical issues include:
security issues
possible breaches of confidentiality
inability of therapists to either protect clients or warn others of potential danger
inability of therapists to read nonverbal responses and clues
potential for client misunderstanding of written communications
client vulnerability due to incompetent therapists
few existing guidelines for ethical practice (exception is Shaw & Shaw’s Ethical Intent Checklist to evaluate online counseling websites)

Addressing Unethical Behavior

When unethical behavior is observed, the behavior should first be discussed directly with the person observed to have acted unethically
If the problem is not resolved at this level, the family therapist should be reported to the appropriate national association (e.g., AAMFT, IAMFC) or licensure/certification board regulating the practice of family therapy
If allegations about a family therapist are made through a client, options include:
check with an attorney or ethics case manager
encourage your client to file an ethics complaint with her or his professional association or licensure/certification board
file a complaint yourself
do nothing, if your professional code does not require you to report
In addressing ethical violations, it can be traumatic for a client to come forward against a therapist

Legal Issues in Family Therapy

Ethical issues often overlap with legal issues
Important legal terms
legal – law or the state of being lawful
law – a body of rules recognized by a state or community as binding on its members
liability – an obligation and responsibility one person has to another
civil liability – results from lawsuit by a client against a therapist for professional malpractice (negligence) or gross negligence
criminal liability – results from the commission of a crime by the therapist, such as failing to report child abuse, engaging in sexual relations with a client, or insurance fraud
administrative liability – results when the therapist’s license to practice is threatened by an investigation from a board which has the power to suspend or revoke the license
Differences between legal and therapeutic systems
legal systems are concerned with gathering evidence based on facts
therapy is more interested in processes and making changes
attorneys spend more time gathering information and concentrating on content than therapists do
legal systems rely on adversity
therapeutic systems rely on cooperation
attorneys focus on ‘winning’ cases for their clients, often discrediting or disproving evidence that contradicts their cases
family therapists affirm family members and work towards equitable resolution of family issues
in the legal system, each family member is represented by a different legal counselor
family therapists work with the whole family to resolve internal disputes
attorneys work with individuals
AAMFT provides its members one free consultation per quarter with legal counsel to discuss legal and ethical practice issues
Types of law
common law – law that is derived from tradition and usage; accepting customs passed down from antiquity such as English law
statutory law – laws passed by legislative bodies and signed by an authorized source; only valid in the jurisdiction in which they are passed
administrative (regulatory) law – specialized regulations passed by authorized government agencies that pertain to certain specialty areas
case law (court decisions) – law that is decided by decisions of courts at all levels from state to federal
civil law – acts offensive to individuals; most applicable to family therapists
criminal law – acts offensive to society in general
family therapists must be aware of their duties and responsibilities in all areas of law and ethics

Legal Situations That Involve Family Therapists

Family therapist may encounter a number of legal situations, for example, dealing with minors, mature minors, age of consent, emancipation, common law marriage, durable power of attorney, and custody issues
Minors. Persons younger than the age of 18 years, who ordinarily cannot enter into binding legal contracts. Mature minors. Persons 16 years or older but younger than the age of 18 years who have demonstrated the ability and capacity to manage their affairs and to live wholly or partially independent of their parents or guardians.
Age of consent. The age at or above which a person is considered to have the legal capacity to consent to sexual activity.
Emancipated minors. Persons who are usually at least 16 years old and are considered adults for several purposes, including the ability to enter into a contract, rent an apartment, and consent to medical care. Emancipated minors include those who are self-supporting and not living at home, married, pregnant or a parent, in the military, and who have been declared emancipated by a court.
Common-law marriages. Sometimes called de facto marriages or informal marriages, these are arrangements by which couples are considered legally married without a having undergone a ceremony or a received a license.
Common law marriages receive the same legal treatment as other types of marriages, including the fact that the couple must go through a divorce to legally end the marriage.
Durable power of attorney. An authorization to act on someone else’s behalf in a legal or business matter
Custody. A legal term describing the relationship between a parent and a child, including the parent’s duty to care for the child and make decisions regarding the welfare of the child.

Therapists may be called on to participate in some legal and legally related situations as expert witnesses, child custody evaluators, reporters of abuse, and court-ordered witnesses.
Expert witness
family therapists may be asked to testify in court about probable causes and recommendations in regard to family members
essential for therapist to remain objective, establish credibility, speak from authority, and be specific
courts are adversarial, with one side seeking to affirm the testimony of the expert witness and the other side working to discredit the expert witness’s testimony
Child custody evaluator
family therapists may be asked to determine what is in the best interest of a child when making child custody arrangements
child custody evaluators represent the child and the court, not the parents
duties may include home visits, testing, and conversations with the child
requires a background and experience in child development, family systems, parenting skills, psychometrics, counseling, and witness testimony
Reporter of abuse
when reporting abuse, family therapists are breaking confidentiality
abuse reporting is mandated in all states
Child Abuse Prevention and Treatment Act of 1974 established mandated reporting for the greater good of society
it is recommended that family therapists advise the family when they are obligated to report abuse and to explain the reporting process
Court-ordered witness
family therapists may be asked to testify in court on behalf of or against a family or family member
if subpoenaed, it is recommended that family therapists immediately seek the advice of an attorney to avoid pressures to take sides and to avoid penalty or perjury situations

Issues of Law in Family Therapy

Malpractice – failure to fulfill the requisite standard of care because of ‘omission’ (what should have been done, but was not done) or ‘commission’ (doing something that should not have been done)
negligence must be proven for a malpractice suit to be brought forward
common malpractice issues include:
advertising – most states place legal limits on practice titles and only professionals who have met specified criteria may call themselves ‘licensed marriage and family therapists’
record keeping – clinical records must be accurate, kept secure, and maintained for a specified length of time
“in camera review” of clinical records is when an impartial party, usually a judge, reviews records and releases on pertinent parts of the clinical record
liability insurance is essential to protect therapists financially from legal claims that they have mishandled family needs or members
Managed care and the process of therapy
- - - third party reimbursement for private practitioners have changed from the traditional 'fee for service' health care system to a 'managed care' health care system
    - managed care systems were created to address a perception of overutilization of benefits and little accountability within the health care industry
    - managed care has resulted in changes for private practitioners
the number of practitioners available to see families
the length of treatment authorized
the types of treatment received
compensation rates
- - - in managed care systems, limits are placed on the amount and type of services provided by close monitoring of services and changing the nature of approved services
utilization review requires practitioners to submit written justification for treatment and comprehensive treatment plans that are submit to review and approval
services not previously authorized or approved are not reimbursed
capitated contracts, an emerging managed care method, are service contracts in which practitioners (called providers) agree to provide treatment for a population for a per person per year fee
due to a high demand to minimize the number of sessions available for reimbursement, brief therapy, solution-focused, narrative, and strategic family therapy approaches have become common
providers must be skilled in drafting treatment plans, following them, and providing evidence of treatment effectiveness
care pathway guidelines have been developed that provide timelines and guidelines which address the decision making process, clinical services offered, and the potential interactions among multidisciplinary health care professions

Professional Identification as a Family Therapist

Who are marriage and family therapists?
AAMFT research on MFTs in the United States in 2004
over 50,000 licensed MFTs
30,000 MFT trainees working toward licensure or completing coursework
two-thirds have masters degrees, one-third doctorates
half of the professionals work exclusively in private practice
one quarter work in institutional or organizational settings
one quarter work in both
two thirds work full time; 21% work part time
most clients are seen during normal business hours
73% also see clients in the evenings
one third see clients on weekends
mean salary in 2004 was $46,573, compared to the overall mean of $43,000 for the general population
income varies greatly due to the diversity of settings, and other factors such as age and experience
mean age is 54
60% of licensed MFTs are women
91% are white
Who seeks marriage and family therapy?
majority are women
ethnic distribution closely resembles the general population
80% white
9% black
10% Hispanic
4% Asian
1% Native American
10% other
children are overrepresented in MFT caseloads
average session length is 59 minutes
two thirds of clients were in therapy for less than one year
treatment approaches
33% use cognitive-behavioral approaches
10% use multi-systemic approaches
6% use psychodynamic approaches
5% use Bowen family therapy
5% use solution-focused therapy
most common presenting problems
mood disorders
couple relationship problems
family relationship problems
anxiety disorders
adjustment disorders
Organizations associated with family therapy
- professional associations
establish standards for the profession, including ethical codes
provide a means for address grievances involving practitioners or the profession in general
provide a means for practitioners to communicate with one another through conferences and publications
provide opportunities for continuing education to keep practitioners abreast of current practices and issues
- American Association for Marriage and Family Therapy
oldest and largest (23,000 members)
established in 1942
focus on accrediting educational programs (COAMFTE)
focus on advocating for MFT licensure at the state level
publishes professional literature and videotapes
Journal of Marital and Family Therapy
Family Therapy News
lobbies for MFTs, including recognition of MFTs as ‘core’ mental health providers
American Family Therapy Association
founded by Murray Bowen in 1977
1,000 members
objectives are
advancing systemic theories and therapies
promoting research and professional education
disseminating information about family therapy
fostering the cooperation of all professionals concerned with the needs of families
promoting the science and practice of family therapy
membership categories include
charter
clinical-teacher
research
distinguished
foreign
annual conference to share ideas and develop common interests
Division 43 of the American Psychological Association: Family Psychology
established to enable psychologists who worked with families to maintain their identity as psychologists
concerned with the science, practice, public interest, and education of psychologists who work with families
annual conference
The Family Psychologist
Journal of Family Psychology
according to L’Abate (1992), family psychologists differ from family therapists in three areas

family psychology is interested in the whole functionality-dysfunctionality continuum, while family therapy is mainly concerned with dysfunctionality
family psychology focuses reductionistically on the relationship of the individual within the family, while family therapy focuses holistically on the family as a whole unit or system
family psychology stresses objective evaluation and primary and secondary prevention approaches, while family therapy stresses the subjective understanding of the family and sees therapy as one type of tertiary prevention

not everyone agrees with L’Abate and there continues to be debate on the identify of family psychology
International Association of Marriage and Family Counselors
a division of the American Counseling Association
regional and national conferences
established national training standards (CACREP)
The Family Journal: Counseling and Therapy for Couples and Families
IAMFC Newsletter
produces training videotapes and publishes books
established standard to credential MFTs
National Council on Family Relations
established in 1939
the oldest professional association dedicated to working with families
focus on education
focus on disseminating information on family history, family forms and functions, and family life in a variety of settings
Journal of Marriage and the Family
Journal of Family Theory and Review
Family Relations: Interdisciplinary Journal of Applied Family Studies
annual conference
Education of family therapists
professional identity is linked to one’s education
educational programs and processes are regulated by accreditation bodies
Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)
Council on Accreditation of Counseling and Related Educational Programs (CACREP)
issues in the education programs in family therapy
professional ‘in-fighting’ for recognition among accreditation boards and professional groups
some professional groups refuse to recognize other similar groups
current programs tend to ignore controversial issues or issues that are hard to teach (e.g., divorce, substance abuse, homelessness, teen pregnancies, extramarital affairs, impact of HIV/AIDS on family life)
Issues in professional identification
practitioners have many choices for professional organizations and alignment
each professional association has unique aspects or foci
friction continues to exist among associations dedicated to family therapy

Key Terms

action-oriented research research that focuses on finding solutions to a problem, such as spouse abuse.

administrative (regulatory) law specialized regulations that pertain to certain specialty areas that are passed by authorized government agencies, for example, laws governing the use of federal land.

American Association for Marriage and Family Therapy (AAMFT) the oldest and largest (23,000 members) professional family therapy organization in the world and dedicated to increasing understanding, research and education in the field of marriage and family therapy, and ensuring that the public's needs are met by trained practitioners.

American Family Therapy Academy (AFTA) a non-profit organization of “leading family therapy teachers, clinicians, program developers, researchers and social scientists, dedicated to advancing systemic thinking and practices for families in their ecological context.”

autonomy in ethics, the right of individuals to make decisions and choices.

beneficience the ethical principle of first do no harm to individuals and work in their best interest.

bug-in-the-ear supervision method a supervision model where the therapist working with a family receives messages from a supervisor through a telephone hookup device.

camera review where an impartial party, usually a judge, reviews a therapist’s records and releases only those portions that are relevant to the situation at hand in a court case.

caring the idea that moral development and principles are centered in the social context of relationships and interdependency.

case law (court decisions) the type of law decided by decisions of courts at all levels from state to federal.

child custody evaluator a family therapist who acts on behalf of a court to determine what is in the best interest of a child in a custody arrangement.

civil law that part of the law that pertains to acts offensive to individuals. Law involving family therapists pertains primarily to civil law—for example, divorce.

common law law derived from tradition and usage.

consultation the use of a neutral third party experts in an area to enhance one’s own knowledge and abilities in that area.

criminal law that part of the law that deals with acts offensive to society in general.

Division 43 of the American Psychological Association (APA): Family Psychology a division of the APA established to enable psychologists who worked with families to keep their identity as psychologists. The division’s mission is to expand both the study and the practice of family psychology, through education, research, and clinical practice.

dual (multiple) relationship a relationship that is not built on mutuality and where a therapist assumes a second role, for example, being a friend, business associate, lover, and so on.

equitability the proposition that everyone is entitled to have his or her welfare interests considered in a way that is fair from a multilateral perspective. Equitability is the basis for relationship ethics.

ethics the moral principles from which individuals and social groups, such as families, determine rules for right conduct. Families and society are governed by relationship ethics.

family therapy supervision a systemic type of supervision that includes a focus on interpersonal as well as intrapersonal issues.

fidelity the ethical prinicple of being trustworthy and keeping one’s promises.

International Association of Marriage and Family Counselors (IAMFC) a division within the American Counseling Association that promotes excellence in the practice of couples and family counseling by creating and disseminating publications and media products, providing a forum for exploration of family-related issues, involving a diverse group of dedicated professionals, and emphasizing collaborative efforts with other marriage and family counseling and therapy groups

justice the ethical principle of treating people equally.

law a body of rules recognized by a state or community as binding on its members.

legal the law or the state of being lawful.

liability a legal term dealing with obligation and responsibility. A liability may be civil, e.g., dealing with professional malpractic such as negligence; criminal, e.g., dealing with the committing of a crime; or administrative, e.g., investigation from a licensure board.

liability insurance insurance that protects therapists financially from legal claims that they have mishandled a clinical situation.

malpractice the failure to fulfill the requisite standard of care either because of omission (what should have been done, but was not done) or commission (doing something that should not have been done). In either case, negligence must be proved.

managed health care a wide range of techniques and structures that are connected with obtaining and paying for medical care, including therapy. The most common are preferred provider organizations (PPOs) and health maintenance organizations (HMOs).

National Council on Family Relations the oldest professional association dedicated to working with families. It was established in 1939, and many of its members helped to create and support the AAMFT. Throughout its history, the NCFR has concentrated on education. Its membership is interdisciplinary and includes family life educators, sociologists, family researchers, and family therapists.

neutrality literally value free; some family therapies pride themselves on operating around a neutrality framework. Critics of such a framework claim that all therapy has moral and political values. A neutrality stance has deep ethical implications.

nonmaleficence the avoidance of doing possible harm to a client from clinical action.

privileged communication a client’s legal right, guaranteed by statute, that confidences originating in a therapeutic relationship will be safeguarded.

professional self-disclosure statement a statement given to the family by the therapist that outlines treatment conditions related to who will be involved, what will be discussed, the length and frequency of sessions, emergency numbers, information about confidentiality and exceptions to it, and fees.

records remembrances in the form of written notes from sessions with couples and families. Records are important for treatment purposes and as a defense for the therapist if he or she is accused of wrongdoing.

relationship ethics Boszormenyi-Nagy’s term for ethics in a family that are based on the principles of equitability and caring.

statutory law that group of laws passed by legislative bodies, such as state and national legislatures, and signed by an authorized source, such as a governor or the president.

Classroom Discussion

1. According to Fishman (1988), in family therapy, some therapists work from an individual therapeutic approach in the presence of the family, or they work with family members individually. This type of treatment raises a value and an ethical question because problems of the family in such an arrangement are not being viewed from their “context as a whole.” Discuss the ethical issues involved in this type of treatment and why it is not considered an effective and/or ethical approach to family therapy practice.

2. Codes of ethics are guidelines developed by professional organizations to address issues confronting marriage and family therapists. However, there are few specific behavioral guidelines on what to do and how. As a result, determining the best course of action from simply reading the code of ethics may be difficult for both beginning and experienced family therapists. How can codes of ethics best be used by practitioners to insure sound ethical practice and quality decision making?

3. How does the considerable in-fighting among professional association groups impact the profession of marriage and family therapy? What would you suggest as strategies to reduce or eliminate this “turfism?”

Multiple Choice Questions

Relationship ethics refer to ethics in a family that are based on the principles of:
1. values and culture
2. equitability and caring
3. behavior and values
4. mutuality and complementarity
There are five primary models and resources for making ethical decisions. They include all the following EXCEPT:
1. educational resources
2. professional consultation
3. action-oriented research
4. codes of ethics
The ethical principle of _____ goes beyond the avoidance of doing possible harm to clients and includes doing good and promoting the welfare of the client.
1. autonomy
2. nonmaleficence
3. beneficence
4. fidelity
The responsibility for maintaining confidentiality lies with
1. the client
2. the therapist
3. both the client and the therapist
4. none of the above
Multicultural competence is necessary to insure therapists do not impose their values on families. One way to avoid serious ethical errors in working with minority culture families is the _____ perspective, which identifies what is culturally significant from the family’s perspective rather than from a prescribed cultural perspective that may not be relevant to a family.
1. gender
2. neutrality
3. culturally relevant
4. interactional
When unethical behavior is observed, the behavior should first be
1. discussed with the person observed to act unethically
2. reported to the appropriate professional association
3. reported to the appropriate licensure/certification board
4. None of the above describe the first step that counselors should take.
Marriage and family therapists may be called to provide testimony in court. One role in which family therapists are asked to testify about probable causes and recommendations in regard to family members is called:
1. child custody evaluator
2. expert witness
3. court ordered witness
4. court advocate
Failure to fulfill the requisite standard of care when providing therapy services can result in
1. an “in camera review"
2. a malpractice suit
3. nonmaleficence
4. dual or multiple relationships
Most marriage and family therapists in the United States practice
1. full time
2. part time
3. some time
4. seldom
Most marriage and family therapy clients are
1. men
2. women
3. childless couples
4. deviant families
Most marriage and family therapists have a
1. bachelors degree
2. master’s degree
3. doctoral degree
4. medical degree
The most widely used treatment approach by marriage and family therapists is:
1. Bowen family therapy
2. psychodynamic approaches
3. cognitive-behavioral approaches
4. solution-focused approaches
The professional association that focuses on accrediting educational institutions and advocating for MFT licensure at the state level is:
1. AAMFT
2. AFTA
3. IAMFC
4. NCFR
What are the two accrediting bodies for marriage and family training programs?
1. COAMFTE and CACREP
2. COAFTA and NCFR
3. CORE and CACREP
4. CAPA and COAMFTE
_____________ results from a lawsuit by a client against a therapist for professional malpractice (negligence) or gross negligence.
1. criminal liability
2. civil liability
3. administrative liability
4. no liability
Which of the following statements is accurate regarding sexual relations between family therapists and the clients with whom they work?
1. It depends on the license under which the therapist is practicing. If it is a professional counselor license, the behavior is appropriate as long as the sexual relations are between two consenting adults.
2. It depends on the theoretical orientation from which the therapists practice. If it is deemed that the theoretical orientation allows for such behavior, then the therapist is justified.
3. All but one of the codes of ethics of family therapy associations forbidden sexual relations between therapists and clients.
4. All codes of ethics of family therapy associations strictly forbid sexual relations between therapists and clients.
Jack, a family therapist, failed to report child abuse. This action would be consider which type of liability?
1. Civil liability
2. Criminal liability
3. Administrative liability
4. Moral liability
Jill, a family therapist, has been struggling with a great deal of interpersonal and finacial stressors since she and her husband decided to separate. Jill believes she can bracket these issues when working with clients. When her financial situation was better, she took on a number of pro bono families. Now, she’s thinking of terminating with some of her pro bono clients so that she can open up space for paying clients. Which metaethical principle regarding loyalty would Jill potentially be breaking if she followed through with this plan?
1. Justice
2. Nonmaleficence
3. Beneficence
4. Fidelity
In which court case was it detrmined that a therapist could not be forced to testify about confidential communications in treatment settings?
1. Tarasoff v. California-Berkeley
2. Jaffe v. Redmond
3. Brown v. Board of Education
4. Seppa v. Marshall
________________________ is a client’s legal right, guaranteed by statute, that confidences originating in a therapeutic relationship will be safeguarded.
1. Privileged communication
2. Professional disclosure agreement
3. Informed consent for testimony
4. None of the above
Third party reimbursement for private practitioners has changed over time from a _____ health care system to a _____ health care system.
1. managed care system; fee for service
2. capitated; utilization review
3. fee for service; managed care
4. preferred provider organization (PPO); health maintenance organization (HMO)
In managed care systems, submitting written justification for treatment and comprehensive treatment plans is called:
utilization review
capitation
fee for service
care pathway guidelines
One way therapists should inform families about the conditions under which therapy will occur is by using a(n):
treatment plan
paradox
clinical note
written professional disclosure statement

Essay Questions

- - 1. Describe what a marriage and family therapist should do if he or she discovered that the law in his or her state contradicts the AAMFT Code of Ethics.
    2. Apply the metaethical principles to the following scenario. You are told by a colleague that a mutual friend’s child, not one of your clients, was complaining of pain in her leg and, when she walks, she exhibits a noticeable limp and grimace. Your colleague shares with you that when he asked how she hurt her leg, the friend’s daughter says her mother hit her with a rolling pin because she back-talked her. Your colleague is asking you what his or her moral, ethical, and legal responsibilities are. What are your legal, ethical, and moral responsibilities, as well as those of your colleague? Remember to support your response with the metaethical principles.

Chapter 7

The Process of Family Therapy

Chapter Overview

Common Factors in Therapy

Four common curative elements in psychotherapy
extratherapeutic factors
therapy relationship
expectancy, hope, and placebo factors
model and technique factors

The Personhood of Family Therapists

Personal characteristics of family therapists contribute to therapy success
Personal therapy can help resolve negative family of origin experiences
Major stressors for family therapists include
listening to client family's problems
less time for one's own family
unrealistic expectations for one's own family
psychological distancing from one's own family due to professional status
Enhancers for family therapists include
increased ability to solve one's own family problems
acceptance of personal responsibility of all family members in contributing to family dysfunction
greater appreciation of one's own family
increased desire and ability to communicate effectively
Successful family therapists appear to have artistic qualities, (i.e., they are intuitive and feeling oriented)

Common Problems of Beginning Family Therapists

Due to inexperience, beginning family therapists often overemphasize and try and do too much, or they underemphasize and fail to make timely interventions that might help the family
Overemphasis
overemphasis on details
two primary components of family therapy are content (details and facts) and process (how information is dealt with in an interaction)
beginning therapists tend to focus more on content rather than process
content is essential but does not tell the whole story
process questions (how the family interacts) are often more revealing than content questions (what, where, and when)
redirection is a technique that asks the family to attend to the process and affective components of their interactions
overemphasis on making everyone happy
beginning therapists often are overly concerned that families leave their offices in a 'happy' state
based on a belief that competent therapists help families solve their problems
beginning family therapists may lack confidence and may be uncomfortable with confrontation and/or friction/disharmony
family discomfort is sometimes unavoidable and can be productive and motivate families to change old behaviors
overemphasis on verbal expression
verbal expressions to families can be very helpful but often are not remembered and may have limited impact over time
it is what the family and family therapist do, as well as what is said, that makes a difference
a variety of therapist tools must be used for maximum impact such as instructing, commenting, asking questions, modeling behavior, role plays, assigning homework outside of the session
both verbal and nonverbal expressions are necessary
overemphasis on coming to an early or too easy resolution
- families often report feeling better after discussing their situation for a few sessions even though they have not actually changed it
- quick and easy resolutions rarely succeed
- family therapy is an ongoing process that will vary for each family and families must be advised regarding time frames and expectations
overemphasis on dealing with one member of the family
families tend to scapegoat one member as the cause of the family problem
family therapists must view the family as a system and the problem as lying within the family system
family therapists must see the family as the unit of treatment, rather than one member of the family
a systemic approach helps family members become more aware of their actions and how they personally contribute to both family health and family dysfunction
Underemphasis
underemphasis on establishing structure
for therapy to be successful, therapy sessions must be conducted differently than the way families normally conduct their family life
the battle for structure refers to the struggle by the therapist to establish effective rules for therapy
the therapist must win the battle for structure so that the family will have a different and more productive experience rather than running the therapy sessions in their own nonproductive ways
family therapists can inform families about the conditions under which therapy will occur by using a written professional disclosure statement or informed consent brochure
fees and payment schedules
theoretical orientations
treatment approaches
rules about appointments
how to contact the therapist
confidentiality and limits to confidentiality
therapist qualifications
risks of therapy
family therapists structure the room by arranging furniture
- to make it easy for family interaction to take place
- to allow for family members to move closer or farther away from each other as necessary during the session
underemphasis on showing care and concern
beginning therapists may treat families more like objects than persons, thus increasing the family's anxiety about therapy
beginning family therapists may appear rigid and distant due to a lack of confidence and experience
effective family therapists are caring, open, sensitive, and show concern and empathy
SOLER is an acronym which describes effective interactive skills for therapists
S means facing the family squarely
O means adopting an open posture that is nondefensive
L means leaning forward to show interest
E means making good eye contact when appropriate
R means to relax and feel comfortable
effective family therapists make self-disclosures and use self-effacing humor when appropriate
underemphasis on engaging family members in the therapeutic process
systemic therapy requires joining with all members of the system
it is important to spend time with each person in the system
rapport and cooperation are increased by acknowledging each person's importance to the family
underemphasis on letting the family work on its problems
- effective family therapists help families become motivated to make changes
- help families to win the battle for initiative (the family's motivation to change) by increasing their hope and the possibilities for change
underemphasis on attending to nonverbal family dynamics
nonverbal cues, such as eye glances, hands folded across one's body, seating arrangements give essential information about family dynamics
ignoring nonverbal family processes gives an incomplete picture of the family and can limit change if not addressed

Appropriate Process

Therapists who do not plan properly are likely to fail

Because family systems are complex, conceptualizing, planning, and implementing interventions also are complex
How to conduct family therapy should be based on one's impression of the family, one's theoretical position, and one's clinical skills

Pre-session planning and tasks

Family therapy begins with the first contact with the family
The family member who initiates the contact may be the one most interested in change and most open to engaging in therapy
Initial contact is best made with the therapist rather than a receptionist so the therapist can answer questions directly, determine who should attend, and how sessions will be conducted
Essential data is collected during the initial contact
Ideally, the initial appointment should be scheduled within 48 hours of the contact
Intake information should be used to develop an initial hypothesis about the family dynamics, life cycle stage issues, ethnic/cultural background, and initial diagnosis of the family problem
A DSM diagnosis of an individual family member may be indicated but does not substitute for a diagnosis of relational problems from a systemic perspective
Family therapists investigate the possible linkages within the family such as what happened, why did it happen, what can be done about it and how?
Family therapists use diagnostic information to come up with a 'case conceptualization,' which is a way to comprehend more thoroughly what is happening with the family members as well as the family as a whole
Case conceptualization is part of the planning process which helps family therapists integrate theory with practice and come up with a treatment plan

Initial session(s)

The first few therapy sessions may be the most critical in terms of success
Most families withhold judgment about family therapy for a few sessions to give treatment a chance to work
Critical factors are a combination of structuring (e.g., teaching, directing) behaviors and supportive (e.g., warmth, caring) behaviors by the therapist
The unit of treatment (i.e., the couple, the family, inclusion of children) is dependent on the theoretical approach used and the comfort level of the therapist
Children are most often included when the therapist is comfortable with children, children are quiet, when the presenting problem is child focused, and with single parent families
Join the family: establishing rapport
the first step in the initial session(s) is establishing a sense of comfort and trust with the family, a process called 'joining'
failure to join with everyone is a common reason for unsuccessful treatment outcomes
Inquire about members' perceptions of the family
begin by finding out how each family member perceives the problem
family members organize their thoughts and behaviors around a 'frame' or perception/opinion which results in predictable patterns of interaction around the problem
knowing how family members frame the problem, person, or situation helps therapists to challenge the family to redefine their perceptions and develop new ways of responding
Observe family patterns
families have unique 'personalities' and characteristic ways of interacting, often referred to as the 'family dance'
the following questions help family therapists determine how families function together
What is the outward appearance of the family?
What is the cognitive functioning in the family?
What repetitive, nonproductive sequences do you notice?
What is the basic feeling state in the family and who carries it?
What individual roles reinforce family resistances and what are the most prevalent family defenses?
What subsystems are operative in this family?
Who carries the power in the family?
How are the family members differentiated from each other and what are the subgroup boundaries?
What part of the family life cycle is the family experiencing and are the problem-solving methods stage appropriate?
What are the evaluator's own reactions to the family?

Assess what needs to be done

assessment is usually done informally, through observation, although diagnostic instruments are sometimes used
the assessment process involves determining what can and what should change to improve family functioning

Engender hope for change and overcome resistance

help families see that things can get better
identifying family strengths and assets helps families recognize their potential for improvement
almost all families exhibit resistance to treatment in some way
controlling sessions
absent or silent members
refusal to talk with each other
hostility
failure to do homework
coming late to sessions
challenging therapist competence
denial
rationalizing
family therapists need to understand the nature of resistance and overcome it without alienating family members
depending on theoretical orientation and how resistance is being used by the family (e.g., fear, defiance), interventions may be chosen to overcome, avoid, or use resistance to produce change
creating boundaries for the family can increase safety and interaction
reframing can give a positive and different interpretation to the family's resistance
family therapists also use the technique of paradox to give families permission to do what they were going to do anyway
regardless of approach, resistance must be addressed in order for treatment to move forward positively

Make a return appointment and give assignments

at the end of the initial session, the family therapist should take the initiative in offering to see the family again
if future sessions have been agreed to, the therapist may assign the family 'homework' or tasks to complete outside the session
homework helps families behave and feel differently and gives them practice time, intensifies the relationship between the therapist and family, and helps the therapist see how the family members relate to one another
homework assignments must be clear and clearly understood by the family
tasks should be practiced in session first if time allows

Record impressions of family session immediately

if not recorded immediately, impressions of families may become difficult to recall and may be distorted over time
clinical notes should be used to record both content and process oriented information
clinical notes can
be studied over time to better understand processes and trends
offer a place to reflect and be objective
serve as a reminder of what has already transpired, avoiding repetitiveness
a unique way of writing clinical notes is to write them in the form of a letter to the family about what occurred in the session

Middle phase of treatment

This is a 'working' stage in which family therapists push family members to make changes and breakthroughs

involve peripheral members
make sure all family members are involved in the process of therapy
invite the least involved member to be an observer of the family
using the technique of circular questioning, ask the least involved member to comment on the different interactions of other family members
use the power of the entire family to physically and verbally insist on participation by reluctant members
seek to connect family members
link individuals with common generational interests and concerns (e.g., siblings)
support coalitions formed for connection, closeness, and growth
break up inappropriate coalitions formed against other family members
establish contracts and promote quid pro quo relations
promote the benefits of relationship changes through contracts (e.g., in return for doing chores, special privileges are granted) or quid pro quo (something for something) in which family members benefit from their interactions together
emphasize some change within the family system
help families understand the change process by helping them see their current situation, options for change, consequences of changing or not changing, and the skills and commitment needed
emphasize that change is often slow and that 'baby steps' now can produce larger changes over time
small changes are less threatening to families and give them time to get used to behaving differently
reinforce family members for trying new behaviors
the most simple way is to use brief, verbal acknowledgments such as 'good' or 'nice work'
a goal is for family members to learn to give each other reinforcement
stay active as a therapist
successful family therapists are mentally, verbally, and behaviorally active with their client families
few approaches to family therapy are passive
family therapists, as a rule, do not count on insight as a primary basis for change
family therapists are actively involved in creating change opportunities for families and do not wait for insight or spontaneous remission of symptoms
link family with appropriate outside systems
- family therapy success can be enhanced through appropriate referral to outside agencies
- do not wait until the end of therapy to make referrals
- Boszormenyi-Nagy stresses that healing and growth for families take place best when the total context in which families operate is included in treatment
focus on process
- focus on process instead of just content tends to produce change
- changes occur over time
- families tend to make the easiest changes first
- family therapists must continuously engage the family in the change process
interject humor when appropriate
- humor can help change family perceptions from seeing their situation as a tragedy which results in hopelessness and paralysis
- using humor does not mean making fun of families but helping them have fun and gain a different perspective on their situation
- Frank Pittman says "If we are fully imbedded in our comic perspective, then we can bear all the reality life has to offer."
look for evidence of change in the family
- closely observe the family for signs of both obvious and subtle changes
- point out changes the family does not readily notice or acknowledge
- discovery of changes may signal moving to the termination stage of therapy

Termination

although it can be at times difficult to pinpoint the exact time to end or change therapy, termination should be a planned for part of the therapy process
termination usually occurs for one of the following reasons
the course of treatment has come to a natural end and there has been improvement (i.e., the goals have been met)
the couple or family's problem exceeds the skills/competency of the therapist
the couple or family are no longer benefiting from therapy
the therapist must leave their employment, temporarily or permanently
the client family can no longer afford treatment and no viable alternatives are available
the termination process involves four steps
- orientation
- summarization
- discussion of long-term goals
- follow-up and relapse prevention
termination can begin by reducing the frequency of sessions
a three session termination procedure
- setting the date
- next-to-the-last session
- final farewell session
rituals and tasks can provide meaning to the termination process and provide a forum to celebrate changes
termination is often premature, with 40% to 60% of families dropping out before therapy is finished
regardless of when termination occurs in the therapeutic process, it should take into account progress made and skills that can be used later

An Example of Appropriate Process in Family Therapy

Initial Sessions
joining and establishing rapport with family are foci of treatment
family dynamics observed in regard to power, boundaries, coalitions, roles, rules, and patterns of communication
importance of typical day and early recollections also important
therapist engenders hope that change can take place
Middle Phase of Treatment
therapist concentrates on helping family members become more aware of their behaviors and to reorient, or become more motivated and want to try new behaviors
Areas of difficulty include:
- changes in perceptions, beliefs, values, and goals
- changes in the structure and organization of the family
- changes in the skills and social behavior of family through teaching
- changes in the way indirect and direct power are employed
  - Termination
begun with mutual agreement
family members encouraged to project ahead and discuss how they might address future problems
follow-up treatment is scheduled

Key Terms

battle for initiative the struggle to get a family to become motivated to make needed changes.

battle for structure the struggle to establish the parameters under which family therapy is conducted.

boundaries the physical and psychological factors that separate people from one another and organize them.

captitated contract a managed care method of cutting costs in which providers agree to provide treatment for a per-person, per-year fee.

care pathway guidelines instructions and directions in the managed care arena that delineate specific timelines in which diagnosis, interventions, decision-making processes, clinical services, and the potential interactions among multidisciplinary health care professionals should occur.

case conceptualization a presession exercise where therapists ask themselves certain questions about couples or families they are going to see in order to form an initial impression of their future clients. This procedure helps them integrate theory with practice and come up with a treatment plan.

content the details and facts.

distancing the isolated separateness of family members from each other, either physically or psychologically.

enmeshment loss of autonomy due to overinvolvement of family members with each other, either physically or psychologically.

family dance the verbal and nonverbal way a family displays its personality.

fee-for-service health care system a system where clients pay for services, such as family therapy, either directly or indirectly through insurance, without being accountable to a third party for specific ways of making interventions.

homework tasks clients are given to do outside of therapy session. Marital and family therapies that are noted for giving homework assignments are behavioral, cognitive-behavioral, psychodynamic, systemic, structural,and postmodern approaches.

informed consent brochure a brochure that includes all the information in a self-disclosure statement about therapy as well as a place for clients to sign off that they understand the policies and procedures involved.

joining the process of “coupling” that occurs between the therapist and the family, leading to the development of the therapeutic system. A therapist meets, greets, and forms a bond with family members during the first session in a rapid but relaxed and authentic way and makes the family comfortable through social exchange with each member.

paradox a form of treatment in which therapists give families permission to do what they were going to do anyway, thereby lowering family resistance to therapy and increasing the likelihood of change.

process how information is handled in a family or in therapy.

quid pro quo literally, something for something.

redirection where the therapist asks the couple or family to attend to the process of their relationship instead of the content of it.

reframing a process in which a perception is changed by explaining a situation from a different context. Reframing is the art of attributing different meaning to behavior.

resistance anything a family does to oppose or impair progress in family therapy.

scapegoat a family member the family designates as the cause of its difficulties (i.e., the identified patient).

SOLAR an acroym, each letter of which stands for the way professional skills may be shown. S stands for facing the couple or family squarely, either in a metaphorical or literal manner. The O is a reminder to adopt an open posture that is nondefensive. L indicates that the therapist should lean forward toward the client family to show interest. E represents appropriate eye contact. R stands for relaxation.

structuring behavior a general term in family therapy for describing the activity of a therapist in teaching and directing.

supportive behavior a general term in family therapy for describing the giving of warmth and care by a therapist.

triangulating projecting interpersonal dyadic difficulties onto a third person or object (i.e., a scapegoat).

utilization review the process in managed health care by which a therapist submits a written justification for treatment along with a comprehensive treatment plan to a utilization reviewer for approval.

Classroom Discussion

1. Successful family therapists appear to have artistic qualities (i.e., they are intuitive and feeling oriented). Explain how having artistic qualities are advantageous and give some examples of how they might be effectively utilized in family therapy.

2. It is widely believed that therapists who do not plan properly are likely to fail. How can therapists blend the need to be flexible, creative, and spontaneous with the structure and rigidity which can be a part of the planning process?

3. Resistance is defined as anything a family does to oppose or impair progress in family therapy. Why is it so important that resistance be addressed in order for treatment to move forward positively? What are some ways of addressing resistance?

Multiple Choice Questions

Beginning family therapists often overemphasize and try and do too much. All of the following are examples of overemphasis except:
details
verbal expression
dealing with one member of the family
establishing structure
SOLER is an acronym which describes effective interactive skills for therapists. In this acronym, the “R” stands for:
relax and feel comfortable
establish roles
reframe
respect the family
Critical factors in the success of the first few sessions are:
verbal and nonverbal behaviors
structuring and supportive behaviors
assessment and data collection
orientation and summarization
In family therapy, establishing a sense of comfort and trust with the family is called:
hypothesizing
circular questioning
joining
engendering hope
Almost all families exhibit resistance of some kind during treatment. Which of the following is an example of resistance:
A client who worries that he is not good enough to live up to his family’s expectations
A client who wonders out loud if counseling is really what the family needs
A family whose conflict resolution style consists of yelling
A family member who attempts to control the counseling sessions
Involving peripheral members and pushing family members to make changes and breakthroughs is a characteristic of which phase of treatment?
initial
middle
termination
none of the above
Termination from treatment is often premature, with _____ of families dropping out before therapy is finished.
10% to 25%
20% to 40%
40% to 60%
60% to 65%
A counselor who attempts to get uninvolved family members to participate by asking him or her to give his or her impressions about the different interactions of other family members is using what technique?
1. Paradoxical intention
2. Reframing
3. Circular questioning
4. Distraction
In which technique does a therapist give families permission to do what they were going to do anyway?
1. Reframing
2. Paradox
3. Circular questioning
4. Homework
The Jones family tend to be overinvolved in each others’ lives, both physically and psychologically. This is called:
1. Healthy attachment
2. Unhealthy triangulation
3. Enmeshment
4. Distancing
When two members of a larger family system group together, they are said to be ________________
1. a triangulate
2. an enmeshment
3. a subsystem
4. a reframe
Which of the following focuses on a family becoming motivated to make changes?
1. Battle for structure
2. Battle for initiative
3. Battle for motivation
4. Framing
Which one of the following must be won by the therapist, otherwise the family members could attempt to run the therapy sessions in a nonproductive manner?
1. Battle for structure
2. Battle for initiative
3. Battle for power
4. Battle to frame
The person whom a family selects as the person who “causes” all the difficulties within the famly is called the __________________.
1. Triangulate
2. Identified patient
3. Scapegoat
4. Recalcitrant
Which one of the following processes consists in a therapist asking a couple or family to attend to the process of the relationship rather than the content?
1. Paradox
2. Circuluar questioning
3. Homework
4. Redirection
____________________ focuses on details and facts; whereas, _____________________ focuses on “how” information is desalt with in an interaction.
1. Content; process
2. Process; content
3. Structure; initiative
4. Initiative; structure
_________________________ is the art of attributing different meaning to behavior so the behavior will be seen differently by the family.
1. Paradox
2. Reframing
3. Circular questioning
4. None of the above
_________________________ refers to something for something, such as children agreeing to do chores if the parents make Saturday dinner a pizza dinner.
1. Reframing
2. Paradox
3. Circular questioning
4. Quid pro quo
Reorientation and change can take place in families by addressing which of the following areas?
1. Changes in perceptions, beliefs, values, and goals
2. Changes in the structure and organization of the family
3. Changes in the skills and social behavior of the family through teaching
4. All of the above
John, a family therapist, scheduled a time with the family several months after their formal treatment ended. This is called _______________.
1. unethical behavior
2. referral
3. follow up
4. post-termination

Essay Questions

Discuss three ways in which counselors overemphasize and three ways in which they underemphasize. For each way, describe potential pitfalls
Describe the process of termination, from orientaiton to follow up.

Chapter 8

Couple and Marriage Therapy and Enrichment

Chapter Overview

Approximately 90% of people in the United States will couple and eventually marry at least once by age 45
Approximately 50% of all marriages fail
Only 3% of married couples seek marital therapy
More than 40% of psychotherapy clients cite marital distress as the reason for seeking services

Types of couple and marriage treatments

Couple and marriage therapy may overall be defined as a process by which a therapist works with two individuals who are in a primary and intimate relationship
couple therapy consists of a therapist working with two individuals as a pair to improve their relationship
marriage therapy consists of a therapist working with a couple that is legally married to help them improve their relationship
more complicated than couples therapy due to legal considerations
premarital counseling consists of a therapist working with a couple to enhance their relationship before they get married
viewed as preventive
focus is on communication skills, conflict resolution skills, finances, and parenting

Preventive approaches to working with couples

Universal prevention
focuses on preventing problems in the general population (e.g., a media campaign on family togetherness)
Selective prevention
focuses on making interventions with at-risk groups to prevent problems (e.g., parenting classes for parents whose children are having difficulty in school)
Indicated prevention
focuses on minimizing the harmful impact of serious problems in the early stages of their development (e.g., working with couples to prevent marital difficulties from resulting in abuse or physical harm to their children)

Major theorists in marriage preparation and couple enrichment

David and Vera Mace
husband and wife team, focused on marriage enrichment (i.e., strengthening marriages before they are in crisis)
first marriage enrichment retreat in 1962
founded the Association for Couples in Marriage Enrichment (ACME) in 1973
authored 33 books on marriage enrichment
John Gottman
Executive Director of the Relationship Institute in Seattle; professor emeritus at University of Washington
mathematical/measurement emphasis in therapy
conducts studies on newly married couples in his Family Research Lab (i.e., The Love Lab); measures heart rate and blood pressure when couple has conflict
has found successful relationships in marriage have a ratio of positive to negative interactions of 5 to 1
prolific writer – more than 20 books and almost 200 academic articles

Major theories for prevention

Marriage and Relationship Education
more cognitive than marriage enrichment (which is more experiential)
use or lectures, visual aids, books, handouts, and interactive discussions
goal is to help couples learn about how relationships work and the rationale behind the strategies for improvement
most premarital counseling programs include at least four topics: communication skills, conflict resolution skills, finances, and parenting
bibliotherapy is an important learning strategy
'Smart Marriage' conferences are popular events for marriage education
Marriage enrichment
a proactive systematic effort to improve the functioning of marital couples
focus on married couples interacting with other married couples, learning from each other
involves self-help and couple-help
structured exercises
sharing information and experiences
confronting areas of conflict
giving and receiving feedback (e.g., communication, finances, problem solving, and having children)
Father Gabriel Calvo
founded Marriage Encounter Program in 1962
team couple leads husbands and wives during a weekend of exercises and sharing of emotions and thoughts
effective communication skills taught
David and Vera Mace
- founded the ACME and its marriage enrichment programs
- husband and wife team lead a structured weekend experience and also provides long term support
- five stages in the ACME process
- security and community building
- developing an awareness of the couple's relationship
- developing knowledge and skills to help improve the relationship
- planning for growth
- celebrating and closure
Bernard G. Guerney, Jr.
- Relationship Enhancement (RE)
- skills building approach
- empathic expression
- discussion/negotiation
- problem/conflict resolution
- facilitation (partner coaching)
- self-change
- other change
- generalization
- maintenance
- use of coaching, modeling, and positive reinforcement
- useful with distressed and nondistressed couples
- solid research base
David Olson
- PREPARE/ENRICH inventories
- PREPARE is used with engaged couples
- ENRICH is used with married couples
- identifies strengths and growth opportunity areas for couples
- five areas of focus
- communication
- conflict resolution
- family-of-origin issues
- financial planning/budgeting
- goal setting
- strong supportive research
- effective with African American as well as European American couples
Training in Marriage Enrichment (TIME) and Prevention and Relationship Enhancement Program (PREP)
TIME is for married couples and can be a weekend or 10-week long program
organized developmentally and sequentially
begins with accepting responsibility and ends with resolving an actual problem
PREP is a 12-week long program focusing on communication and problem solving skills and enhancing commitment to the relationship
research supports long lasting benefits from these programs
Other programs
Couples Communication Program (CC)
Great Start
SANCTUS
Practical Application of Intimate Relationship Skills (PAIRS)

Marriage and Couple Therapy

Research support for reducing conflict, increasing marital satisfaction
Conjoint therapy more effective than individual treatment
Major theorists
Susan Johnson
developed emotionally focused therapy (EFT) in the mid-1980s
an alternative to behaviorally focused approaches at the time

Therapeutic Approaches for Working with Couples

Psychoeducational approaches combined with marriage therapy can make marriages stronger
Crisis oriented approaches are less effective in the long term than approaches with developmental perspectives
Half of all couples treated eventually return to original levels of relationship discord
Primary reasons for seeking marital therapy
lack of communication
financial stress
disagreements over priorities
infidelity
All approaches focus on improving marital quality (how the relationship is functioning and how partners feel about and are influenced by the functioning)
Assessment is complex
"feelings expressed about marriage are greatly affected by the events of the moment and can change considerably over short periods of time . . . Additionally, individuals in distressed relationships sometimes do not report themselves distressed" (Lebow, 2005, p. 38)
Common factors among all approaches
establishment of a therapeutic alliance with the couple
goal oriented in deescalating negative reciprocity
building of positive interactions
monitoring treatment progress
successful termination

Behavioral Couple Therapy (BCT)

Premises of the theory
based on the exchange/negotiation model of adult intimacy
combines problem solving and communication skills with behavioral contracting
Treatment techniques
focuses on negotiating pleasant behaviors and teaching problem solving and communication skills
techniques include positive reinforcement, shaping, modeling
contingency contracts describe the terms for behaviors and reinforcers, one action being contingent on another
operant interpersonal approach based on the assumptions of exchange theory and quid pro quo that successful relationships are rewarding
'caring days' is a creative technique in which couples act as if they care about their spouses, regardless of the other's actions
'positive risk,' is a unilateral action that is not dependent on another for success
Process and outcome
behavioral analysis to assess the marital distress
positive reciprocity to increase rewarding and valued behaviors
communication skills training to increase use of "I" statements, develop behavioral labels, and provide positive feedback
problem solving to develop conflict resolution and negotiation skills
Unique aspects of behavioral couple therapy
well researched
works best with young couples without a long history of marriage
more effective than individual treatment with alcoholics and, with this population, reduces social costs, domestic violence, and problems of the couple's children
Comparison with other theories
a specific and precise skills-based approach
more linear than systemic
Offshoots of behavioral couple therapy
integrative behavioral couple therapy (IBCT)
- promotes acceptance as well as change
- helps identify areas of the relationship unlikely to change and coming to terms with those problems
- reframing of hard emotions (e.g., hostility) to softer emotions (e.g., sadness)
- results are less blaming and more soft emotions, increased empathy and emotional closeness, and long lasting change
cognitive-behavioral couple therapy (CBCT)
empirically supported, highly effective, short term in nature
used psychodynamic, cognitive, behavioral, and humanistic constructs
first introduced by Albert Ellis and his Rational Emotive Therapy (called Rational Emotive Behavior Therapy today)
ABC procedure (A is the event, B is the thought produced by the event, C is the emotion produced)
individuals and couples choose to think and feel in one of four ways:
positive
negative
neutral
mixed
forms of cognition that cause marital distress
selective perceptions about the events occurring in couple interactions
distorted attributions about causes of positive and negative relationship events
inaccurate expectations or predictions about events that may occur in the relationship
inappropriate or inaccurate assumptions or general beliefs about the characteristics of people and their intimate relationships
extreme or unrealistic standards to which individuals hold relationships and their members
other cognitive behavior methods include
cognitive distraction (thinking of something other than negative aspects)
self-control strategies (how to use rational coping statements)
relapse prevention (learning self-control strategies to prevent relapse)
psychoeducational methods (reading books, attending workshops, listening to audiovisual materials)

Emotionally Focused Therapy

A systemic approach based on integration of experiential and structural family therapy
Focus on dual perspectives of intrapsychic processes (processing of emotional experiences) and interpersonal processes (patterns and cycles of partner interactions)
Approach is rooted in attachment theory
secure attachment is related to higher self-esteem, internal locus of control, extroversion, openness to experience
insecure attachment often stems from family-of-origin issues and is expressed in the form of put-downs, belligerence, lecturing, stonewalling, and anger
Interventions include both experiential and structural techniques
Goal is to soften intense emotions to help build attachment and connectedness
Treatment techniques
focuses on disclosure of feelings
therapist may interrupt arguments and disagreements and reflect with each member as a means of defusing hostility
members explore the perceptions behind partners' emotional responses and
catharsis is encouraged along with self-awareness
techniques from Gestalt and psychodrama approaches may also be used
Role of the therapist
provides a safe environment for release of both positive and negative emotions
encourages emotional expression while protecting the couple as individuals and partners
Process and outcome
three stage interaction process with nine steps
cycle deescalation (steps 1-4)
designed to uncover negative or hard feelings
restructuring interactional positions (steps 5-7)
explore intrapsychic processing of attachment related affect
work to create new interactive patterns
externalize the problem into a relationship problem rather than an individual problem
consolidation/integration (steps 8-9)
review accomplishments
reinforce secure bonding interactions
restructure interactions more positively
Unique aspects of Emotionally Focused Therapy
strong empirical base
process research oriented
timing of positive/negative interaction important change element
appropriate for couples from all backgrounds
wide application
post-traumatic stress disorder
moderately distressed couples
families with a bulimic child
couples suffering from trauma
couples with depression and chronic illnesses
older couples
gay couples
new focus on forgiveness and reconciliation, attachment injuries, and relationship traumas
70% recovery rate for distressed couples
90% overall recovery rate for all couples
Comparison with other theories
stronger emphasis on emotion and the concept of self than most theories
strong emphasis on empirical validation
demonstrates efficacy apart from its originators

Infidelity

Unfaithfulness in marriage

having an affair
extramarital relationships
cheating
sexual intercourse
oral sex
kissing
fondling
emotional connections that are beyond friendships
friendships
internet relationships
pornography use
Infidelity is common in American society
Approximately 25% of men and 10% of women have affairs sometime during marriage
Risk factors include
race (African Americans)
gender (males)
age (younger couples)
employment (working outside the home)
infrequent church attendance
low marital satisfaction
Approaches for treating infidelity
assess for cultural context as culture may define how a couple view unfaithfulness
infidelity is one of the most damaging problems couples face and one of the most difficult to treat
three recovery stages
an emotional roller coaster of emotions
a moratorium
trust building
stages may be sequential but the recovery process is uneven and includes regressive moments
Should the act of infidelity be revealed in therapy and how much should be told?
one model of therapy requires no disclosure and respects self-determinism; most prevalent outside the United States
second model of therapy requires the noninvolved spouse be made aware of the affair if it has not been previously disclosed before therapy begins; if an affair is kept secret, it cannot be treated
behavioral couple therapy is effective in cases of infidelity
cognitive-behavioral approaches can emphasize forgiveness and ‘letting go’ of resentment, bitterness, and the need for vengeance
therapist must instill hope to the couple that they can make it
it is common for many couples to separate and divorce rather than trying to continue their lives together

Divorce Therapy, Mediation, and Collaboration

Divorce Therapy

All marriages have some conflict
25% of couples seeking divorce report seeking professional help
Those couples who do seek help wait an average of 6 years following onset of a serious problem before actually seeking help
Reasons for divorce are many, including marital stress and dissatisfaction, and physical assault
Therapists must assess whether or not their efforts will be toward salvaging a relationship or assisting with its dissolution
Three common ways of dissolving relationships are through divorce therapy, mediation, and collaboration
Divorce therapy helps couples separate from each other physically, psychologically, and/or legally
Goals include
accepting the end of the marriage
achieving a functional post divorce relationship with an ex-spouse
achieving a reasonable emotional adjustment and finding emotional support
coping with religious or spiritual angst
realizing the part one played in the dissolving of the marriage
helping the children from the marriage (if there are any) adjust to the loss
using the crisis of the divorce as opportunity to learn about oneself and to grow\
negotiating a reasonably equitable legal settlement
developing healthy habits
Techniques
reading
reflecting
participation in structured exercises
listening for feelings
shifting “you” statements to “I” statements
setting aside specific time to discuss problem issues
learning to fully attend to one’s partner during conflict without interrupting
avoiding “dumping” of past unresolved issues or behaviors
refraining from physical actions and/or advice giving
postponing resolution, if needed, until the couple can reenergize and think through issues

Family Mediation

Process of helping couples and families settle disputes or dissolve their marriages in a nonadversarial way
A viable alternative to court action
Family/couple mediators are specially trained to function as impartial and neutral third parties to facilitate negotiation between disputing parties
Objective is to help the disputing parties make informed and mutually agreed upon decisions that resolve their differences in a practical and fair manner
Steps include
obtain a brief history
gather data about assets, incomes, liabilities, and goals
prioritize important issues
When compared to divorce proceedings, mediation is quicker, less costly, less hostile and stressful, and more productive
Part of the mediation process is teaching disputing parties how to bargain and come to a fair agreement
Mediation is conducted within external deadlines and concludes with a negotiated written contract
For more information
Academy of Family Mediators
Association of Family and Conciliation Courts
National Institute for Dispute Resolution
Society for Professionals in Dispute Resolution

Collaborative Divorce

An intervention model in which the divorcing couple and attorneys agree, by an explicit, written contract, to work toward a settlement without resorting to litigation.
Training collaborative attorneys support their respective clients in negotiating a settlement in a four-person meeting (two attorneys, two spouses)
If either party in the procedure decides to pursue litigation both collaborative attorneys are automatically terminated and each client hires new litigation attorneys
Other professional, including those in mental health (called “coaches”), meet with clients three or four times prior to and during the decision to divorce to help clients manage their feelings
Financial planners, CPAs, and appraisers may also be consulted during the collaborative divorce proceedings

Key Terms

behavioral analysis a procedure used in behavioral couples therapy to measure couple distress. It is based on interviewing, self reports on questionnaires, and making behavioral observations.

caring days part of a behavioral marital procedure in which one or both marital partners act as if they care about their spouse regardless of the other’s action(s). This technique embodies the idea of a “positive risk”—a unilateral action not dependent on another for success.

collaborative divorce an intervention model in which the divorcing couple and attorneys agree, by an explicit, written contract, to work toward a settlement without resorting to litigation

communications theory an approach to working with families that focuses on clarifying verbal and nonverbal transactions among family members. Much communication theory work is incorporated in experiential and strategic family therapy.

contingency contracting a procedure in which a specific, usually written, schedule or contract describes the terms for the trading or exchange of behaviors and reinforcers between two or more individuals. One action is contingent, or dependent, on another.

couple therapy when a counselor works with two individuals to improve their relationship as a dyad. The couple may be married or unmarried, gay or straight, and have various levels of commitment to each other.

Couples Communication Program a marriage enrichment program which is divided into entry and advanced programs where couples learn about themselves and their partners better in addition to mastering 11 interpersonal skills for effective talking, listening, conflict resolution, and anger management

Great Start a program that utilizes PREPARE/ENRICH inventories and is designed for premarital and early marital relationships. It is a part of the Couples Communication Program.

incest sexual relations between people who are closely related in a family, such as a parent/child or siblings, that is illegal or forbidden by custom.

indicated prevention preventive efforts that focus on minimizing the harmful impact of serious problems in the early stages of their development, such as having a therapist work with a couple whose marriage is coming apart in order to prevent them from doing harm to one another or harm to their children.

infidelity a myriad of activities outside of a couple relationship including: ‘having an affair,’ ‘extramarital relationships,’ ‘cheating,’ ‘sexual intercourse,’ ‘oral sex,’ ’kissing,’ ’fondling,’ ‘emotional connections that are beyond friendships,’ ’friendships,’ ‘internet relationships,’ ‘pornography use,’ and others.

marital quality how a marriage relationship is functioning and how partners feel about and are influenced by such functioning.

marriage education the use of didactic lectures, visual aids, books, handouts, and interactive discussions to help couples learn about the pitfalls and possibilities of marriage.

marriage enrichment the concept that couples stay healthy or get healthier by actively participating in certain activities, usually in connection with other couples.

marriage therapy when a therapy works with a couple that is legally married to help them improve their relationship.

Marriage Encounter Program founded in 1962, the essence of this approach is to have a “team couple” lead a group of husbands and wives during a weekend in exercise that give them the opportunity to share their emotions and thoughts. In essence, couples are taught how to make effective communication a part of their everyday lives.

operant conditioning a tenet of Skinner’s behavioral theory that people learn, through rewards and punishments, how to respond to their environments.

operant interpersonal approach the term first used to describe Richard Stuart’s initiatives in behavioral couple therapy.

Practical Application of Intimate Relationship Skills (PAIRS) a marriage enrichment program developed by Lori Gordon that teaches attitudes, emotional understandings and behaviors that nurture and sustain healthy relationships

positive reinforcer a material (e.g., food, money, or medals) or a social action (e.g., a smile or praise) that individuals are willing to work for.

positive risk a unilateral action that is not dependent on another for success.

premarital counseling working with a couple to enhance their relationship before they get married.

quid pro quo literally, something for something.

SANCTUS a theologically and psychologically based marriage enrichment program based on step-wise process that incorporates building a pattern of love and relationship with God, one’s self, and others

selective prevention preventive efforts that focus on making interventions with at-risk groups in order to prevent problems such as conducting parenting classes for parents whose children are having difficulties in school.

shaping the process of learning in small gradual steps; often referred to as successive approximation.

social exchange theory an approach that stresses the rewards and costs of relationships in family life according to a behavioral economy.

social learning theory a theory that stresses the importance of modeling and learning through observation as a primary way of acquiring new behaviors.

universal prevention prevention efforts that focus on preventing the development of problems in the general population, such as a media campaign promoting family togetherness.

Classroom Discussion

1. In cases of infidelity, should the act of infidelity be revealed in therapy and, if so, how much should be told?

One model of therapy requires no disclosure and respects self-determinism. This model is most prevalent outside the United States. A second model of therapy requires the noninvolved spouse be made aware of the affair if it has not been previously disclosed before therapy begins; if an affair is kept secret, it cannot be treated.

What are the pros and cons of each approach? In what circumstances might each approach be recommended? Contraindicated?

2. Couple and marriage therapy approaches encompass both systemic and linear orientations. What are the advantages and disadvantages of each perspective in treating distressed couples?

3. How do therapists go about deciding when marital therapy becomes divorce therapy? What other factors might go into such decisions (e.g., personal values, religion, theoretical orientation)?

Multiple Choice Questions

In premarital counseling, the focus is on _______________.
1. prevention
2. enrichment
3. generalization
4. all of the above
The overall goal of marriage enrichment, education, and enhancement programs is to
1. settle disputes or dissolve marriage in nonadversarial ways
2. improve the functioning and quality of marriages
3. explore intrapsychi processing
4. resolve family of origin issues
There are three preventive approaches to working with couples. They are:
1. primary, secondary, tertiary
2. premarital, education, enrichment
3. universal, selective, indicated
4. premarital, psychoeducational, conflict resolution
Crisis oriented couples approaches are _____ effective in the long term than approaches with developmental perspectives.
1. more
2. less
3. about the same
4. there is no such comparison
Which couples therapy approach focuses primarily on negotiating pleasant behaviors and teaching problem solving and communication skills?
1. Behavioral Couple Therapy
2. Emotionally Focused Therapy
3. Cognitive-Behavioral Couple Therapy
4. Integrative Behavioral Couple Therapy
Which couples therapy approach focuses on the dual perspectives of intrapsychic processes and interpersonal processes?
1. Behavioral Couple Therapy
2. Emotionally Focused Therapy
3. Cognitive-Behavioral Couple Therapy
4. Integrative Behavioral Couple Therapy
A procedure used in behavioral couples approaches in which one or both partners act as if they care about each other, regardless of the other’s actions, is called:
1. behavioral analysis
2. self-analysis
3. gunnysacking or dumping
4. caring days
The process of helping families or couples settle disputes or dissolve their relationships in a nonadversarial way is called:
1. marriage education
2. marriage encounter
3. relationship enhancement
4. mediation
Important goals of divorce therapy would include all the following EXCEPT:
1. building attachment and connectness
2. coping with religious or spiritual angst
3. accepting the end of the marriage
4. negotiating a reasonably equitable legal settlement
Mediation, when compared to divorce proceedings, is _____.
1. quicker
2. less costly
3. less hostile
4. all of the above
Infidelity in American society is:
1. rare
2. increasing
3. decreasing
4. common
Risk factors for infidelity are higher for _______________ and ________________.
1. European Americans; females
2. African Americans; males
3. older couples; individuals working outside the home
4. individuals experiencing low marital satisfaction; those with frequent church attendance
In treating cases of infidelity, three recovery stages have been identified.
1. Stage 1 a moratorium

Stage 2 an emotional roller coaster of emotions

Stage 3 trust building

1. Stage 1 an emotional roller coaster of emotions

Stage 2 trust building

Stage 3 a moratorium

1. Stage 1 trust building

Stage 2 a moratorium

Stage 3 an emotional roller coaster of emotions

1. Stage 1 an emotional roller coaster of emotions

Stage 2 a moratorium

Stage 3 trust building

Which of the following is considered an effective treatment for infidelity?
1. Multisystemic
2. community reinforcement
3. Behavioral Couple Therapy
4. Structural Family Therapy
When treating cases of infidelity, it is important for therapists to assess for the _____ context, as this may define how a couple view unfaithfulness.
1. historical
2. cultural
3. narrative
4. self-determinism
In the SMART mnemonic, what does the “R” stand for?
1. Rest
2. Relax
3. Resist
4. Recruit
Which one of the following is NOT a stage, or blueprint, of the Sound Relationship House Theory?
1. Assessment of the couple’s emotional connection and conflict
2. Enhancement of the couple’s friendship
3. Improvement of the couple’s conflict management
4. Reinforcement of the advancements that have take place
5. All of the above are blueprints of the SRH
Dave, a couples therapist focuses on making interventions with at-risk groups in order to prevent problems. In what type of prevention is Dave engaged?
1. Universal
2. Selective
3. Indicated
4. None of the above
Of the popular instruments used to work with couples, which is considered the easiest instrument to interpet and to use in large groups and teaching settings?
1. PREPARE
2. FOCUS
3. PAQ
4. RELATE
_____________________ is defined as a therapist working with two individuals to improve their relationship as a dyad.
1. Group therapy
2. Couple therapy
3. Marriage and Family Enrichment Education
4. Strategic Family Therapy

Essay Questions

Compare and contrast the major tenets of behavioral couple therapy and emotionally focused therapy.
Describe what collaborative divorce is and the role of family counselors/therapists in it.

Chapter 9

Psychodynamic Family Theory

Chapter Overview

Psychodynamic Family Therapy

Major theorists

Nathan Ackerman
began with an interest in families and their influence on mental health and illness
treated whole families and conducted staff home visits at the Menninger Clinic
established the Family Institute in 1960 (later called the Ackerman Institute for the Family)
cofounder of Family Process, the first journal in family therapy
new concepts included
‘tickling of defenses’ (i.e., provoking family members to open up and say what was on their mind)
complementarity
focus on strengths
interlocking pathology

Premises of the Theory

human nature is based on drives (e.g., sexuality and aggression)
mental conflict arises when children learn, and mislearn, that expressing basic impulses leads to punishment
conflict is signaled by unpleasant affect such as depression or anxiety
unconscious processes, called interlocking pathologies, take place among family members that keep them together
more recent focus is object relations theory
an object is something that is loved, usually a person
object relations means “relations between persons involved in ardent emotional attachments”
humans have a basic motivation to seek objects, starting at birth
children often internalize (interject) good and bad characteristics of these objects within themselves
interjections form the basis for how individuals interact and evaluate their interpersonal relationships
evaluating relationships can result in splitting (viewing object representations as either all good or all bad)
results in projection of good and bad qualities onto persons within one’s environment
splitting helps people control their anxiety and even their objects, by making them predictable
splitting distorts reality
object relations theory helps explain reasons for marital choice and family interaction patterns

Treatment techniques

transference (the projection onto a therapist of feelings, attitudes, or desires)
used to understand dominant feelings within a family and identify which emotions are being directed toward what people
helps with the expression of pent-up emotions (i.e., catharsis)
dream and daydream analysis
helps identify and analyze what needs within the family are not being met and that may need attention
confrontation
pointing out behavioral contradictions or conflicts with expressed wishes
focusing on strengths
concentrating on strengths helps change the family’s focus
life history
identifies past and present interactional patterns
affirms value and acceptance of all family members
promotes trust in the therapist
provides insight for family members
complementarity
the degree of harmony in the meshing of family roles
interpretation
brings unconscious conflicts between family members into consciousness (makes the covert overt)
helps to increase family members’ insight into how the past is continuing to affect the present

Role of the therapist

teacher
good enough mother (e.g., nurturing, encouraging)
catalyst (e.g., activates, challenges, confronts, interprets, integrates family processes)
emphasis on family as well as individual interactions

Process and outcome

therapist’s interpretation of events
insight by family members
interpretations best offered at the preconscious level
insights translated into new and more productive ways of behaving and interacting
differentiation (i.e., balance of rational and emotional selves and separation of self and others in a non-anxious way)
if differentiation is not possible, crisis resolution (reduction in symptoms) is utilized, focusing more on supporting defenses and clarifying communication

Unique aspects of Psychodynamic Family Therapy

focus on the importance of the unconscious in influencing human behavior
raises awareness of intrapersonal and interpersonal connections, such as invisible loyalties
examines basic defense mechanisms and their influence on family interactions
emphasizes the historical origins of dysfunctions and the treatment of persons and families so affected
explains how persons form attachments and how family members function as a result
Comparison with other theories
linear, not circular
requires long-term commitment of time and money
requires higher than average intellectual ability
requires abstract thinking skills
lacks empirical research

Key Terms

catalyst the role that a psychodynamic family therapist plays by moving into the “living space” of the family and stirs up interactions.

crisis resolution a treatment modality used in crisis situations where the therapist focuses most on supporting defenses and clarifying communication in order to help a family.

detriangulation the process of being in contact with others and, yet, emotionally separate.

differentiation (of self) a level of maturity reached by an individual who can separate his or her rational and emotional selves. Differentiation is the opposite of fusion.

family projection the tendency of couples according to Bowen to produce offspring at the same level of differentiation as themselves.

fused when someone is emotionally overinvolved with someone else.

fusion the merging of intellectual and emotional functions so that an individual does not have a clear sense of self and others. There is a discomfort with autonomy in relationships, wishes to psychologically merge with another, and difficulty tolerating differences of opinion. Fusion is the opposite of differentiation.

good enough mother a mother who lets an infant feel loved and cared for and thereby helps the infant develop trust and a true sense of self.

interlocking pathology a term created by Ackerman to explain how families and certain of their members stay dysfunctional. In an interlocking pathology, an unconscious process takes place between family members that keeps them together.

invisible loyalties unconscious commitments that grown children make to help their families of origin, especially their parents.

multigenerational transmission process the passing on from generation to generation in families of coping strategies and patterns of coping with stress. In poorly differentiated persons, problems may result, including schizophrenia.

off-schedule events major life events, such as marriage, death, and the birth of children occurring at different times than is the norm.

pseudo-individuation/pseudo-self a pretend self. This concept involves an attempt by young people who lack an identity and basic coping skills to act as if they had both.

societal regression the deterioration or decline of a society struggling against too many toxic forces (e.g., overpopulation and economic decline) countering the tendency to achieve differentiation.

tickling of defenses Nathan Ackerman’s term for provoking family members to open up and say what was on their mind.

transference the projection onto a therapist of feelings, attitudes, or desires.

triangle the basic building block of any emotional system and the smallest stable relationship system in a family.

triangulating projecting interpersonal dyadic difficulties onto a third person or object (i.e., a scapegoat).

undifferentiated an emotional dependency on one’s family members, even if living away from them.

undifferentiated family ego mass according to Bowen, an emotional “stuck togetherness,” or fusion, within a family.

Classroom Discussion

1. Psychodynamic approaches have been criticized for having a strong historical focus, the concern being families may focus on their history rather than present issues and problems. What are the advantages and disadvantages of only focusing on an historical approach?

2. Objectivity and neutrality are important therapist characteristics in psychodynamic approaches. What are some potential areas for therapists to be aware of and what are some ways to insure higher levels of objectivity and neutrality?

Multiple Choice Questions

Which of the following statements most accurately describes transgenerational family therapies?
They examine the interactions of families across generations as a way of understanding currnet problems and predicting future challenges.
They emphasize the future-orientation of human systems, as they evolve into having more complex feedback loops.
They emphasize the timeless efforts of Freud and his psychodynamic colleagues.
They only include the theoretical beliefs of Nathan Ackerman.
Provoking family members to open up and say what is on their mind is a technique known as
focusing on strengths
complementarity
family projection process
tickling of defenses
Splitting is a way of evaluating relationships that result in viewing object representations as:
all good or all bad
predictable or unpredictiable
internalized or externalized
interlocking pathologies
Which of the following refers to an unconscious, dysfunctional process that takes place between family members that keeps them together?
1. Interlocking pathology
2. Splitting
3. Complementarity
4. Family projection process
A psychodynamic family therapy treatment technique used to understand dominant feelings within a family and identify which emotions are being directed toward what people is called:
1. dream and daydream analysis
2. confrontation
3. transference
4. complementarity
Psychodynamic family therapy is primarily _____ in nature.
1. short term
2. action oriented
3. linear
4. systemic
Which of the following refers to relations between persons involved in ardent emotional attachments?
1. Differentiation
2. Emotional diffusion
3. Triangulation
4. Object relations
Which theorist established the Family Institute in New York in 1960, as well as became the cofounder of Family Process?
1. Alfred Adler
2. Nathan Ackerman
3. Carl Jung
4. Donald Williamson
__________________ refers to the projection of feelings, attitudes, or desires of a significant other onto a therapist.
1. Splitting
2. Differentiating
3. Deflection
4. Transference
Which of the following is the objective of dream analysis in psychodynamic family therapy?
1. From a Jungian, spirituality perspective, dream analysis helps therapists determine the collective spiritual connectedness/disconnectedness of family members.
2. Dream analysis helps family members and therapist predict future opportunities and challenges of a family.
3. Having family members discuss their dreams allows for analysis of unmet needs within the family.
4. Contrary to media depictions, dream analysis does not occur in psychodynamic family therapy.
An internal thought of, “I want to buy a new car, but I think I should save my money,” changed to “I want a new car, but my wife thinks we should save our money,” is an example of __________________.
1. Projective identification
2. Intrapsychic defense
3. Splitting
4. Confrontation
When a therapist points out to families how their behaviors contradict or conflict with expressed wishes, the therapist is using what psychodynamic technique?
1. Projective identification
2. Confrontation
3. Fusing
4. Joiniing
Which of the following terms is the degree of harmony in the meshing of family roles?
1. Interpretation
2. Role enmeshment
3. Complementarity
4. Family reflection
_______________ is a psychodynamic therapist role in which the therapist moves into the “living space” of the family and stirs of interactions.
1. Catalyst
2. Good enough uncle
3. Joiner
4. Oedipalist
_______________ refers to the point at which individuals have reached a level of maturity at which they can balance their rational cognitive and emotional selves and can separte themselves from others in a nonanxious way.
1. Catalyzation
2. Differentiation of self
3. Sublimation
4. Individuation
Bill expresses a deep passion for fidelity and loyalty in marriage by frequently expressing his admiration and love for his wife on bumper stickers and social media posts. Acquaintances of Bill are shocked to learn that he was caught in a sting operation in which he was soliciting a prostitute. The inconsistencies in Bill’s expressions and behaviors could be conceptualized as which ddefense mechanism?
1. Displacement
2. Dissociation
3. Reaction formation
4. Intellectualization
___________________ is a lesser form of dissociation, wherein parts of oneself are separated from aweareness of other parts and behaving as if one had separate sets of values.
1. Reaction formation
2. Intellectualization
3. Compartmentalization
4. Displacement
Bill receives a reprimand from his administrative supervisor at work. When he gets home, he yells at his young children for not doing their chores quickly enough. Bill’s behavior is an example of _____________.
1. Displacement
2. Reaction formation
3. Dissociation
4. Intellectualization

Essay Questions

Choose three defense mechanisms. Describe what each is and give an example of how each may play out in a family.
How is psychodynamic family therapy similar to and different from other theories?

Chapter 10

Bowen Family Systems Theory

Chapter Overview

Bowen Family Therapy

Among the first systemically based approaches for working with families
Also known as transgenerational family therapy due to its historical focus
Major theorists
Murray Bowen
the originator of this approach
started working with families at the Menninger Clinic
studied “mother-patient symbiosis”
studied dynamics of families with schizophrenic children
initiated the founding of AFTA
Premises of the theory
theory and therapy cannot be separated
patterns passed down from previous generations must be examined and changed to avoid repetition in current families
risk for problems associated with family members who are emotionally overinvolved (i.e., fused) with each other or emotionally cut off (psychologically or physically) from each other
low anxiety results in few problems for people or families
eight basic concepts of Bowen Family Therapy
differentiation
a level of maturity reached by individuals who can distinguish themselves from their families of origin and separate their rational and emotional selves.
differentiation is the opposite of fusion.
continuum from autonomy (an ability to think through a situation clearly) to undifferentiated, also called fusion or undifferentiated family ego mass (emotional dependency on one’s family members)
emotional system
emotional reactivity
emotional cutoff
fusion with others
ability to take an “I-position”

multigenerational transmission process

patterns and strategies of coping with stress that are passed on from generation to generation
selection of marital partners at one’s own level of differentiation

nuclear family emotional system

low levels of anxiety produce stress, illness, and chronic dysfunction
high levels of anxiety produce rapid emotional equilibrium after the stress passes

family projection process

tendency to produce offspring at the same level of differentiation as the couple
poorly differentiated spouses keep emotional distance from one another
when anxiety gets too great, result may be marital conflict, physical or emotional illness in one spouse, projection of the problem to the children, or a combination of these

triangles

the basic building block of any emotional system
the smallest stable relationship system
some triangles are healthy, others are not
triangles are a frequent way of dealing with anxiety in which tension between two persons is projected onto another object
detriangulation helps people separate their feelings from their intellect, reducing anxiety
multigenerational genograms (a type of family tree) helps people detriangulate
homework assignments to visit their families and ask questions also help reduce anxiety

sibling position

people can develop fixed personality characteristics based on their functional birth order

societal regression

the deterioration or decline of a society struggling against too many toxic forces (e.g., overpopulation and economic decline) countering the tendency to achieve differentiation

Treatment techniques

focus is on the process of differentiation
genograms
a visual representation of a person’s family tree
minimum of three generations
tracks relationship changes
repetitive patterns
coincidences
impact of change and life cycle transitions (e.g., off schedule events)
trends
shifts from emotional reactivity to clear cognitions
www.genopro.com
going home again
clients/family members instructed to return home to get to know their family of origin better
individuals may need to practice staying calm before returning home
detriangulation
the process of being in contact and emotionally separate
two levels
resolving anxiety over family situations and not projecting feelings onto others
separating one’s self from becoming a focus when tension or anxiety arises in the family, avoiding scapegoating or blaming
person-to-person relationships
helping two family members relate to each other about each other without talking about others or about impersonal issues
differentiation of self
the degree to which a person is able to distinguish between the subjective feeling process and the more objective intellectual (thinking) process
may involve all the previous techniques as well as confrontation between family members and the therapist
asking questions
a main tool of Bowen therapists
helps people to understand the reactions of those in their families better
Role of the therapist
differentiation of the therapist is crucial
objectivity and neutrality are important therapist characteristics
coaching
teaching
having family members talk through the therapist to reduce emotional reactivity
setting an example of a reasonable, neutral, self-controlled adult
helping clients look for “clues” to identify where family pressures have been expressed and how the family has adapted
assist with drawing genograms
interpret multigenerational patterns of fusion and cut offs

Process and outcome

family members will understand intergenerational patterns and gain insight into historical experiences that influence current interactions
family members increase levels of differentiation
primary unit of treatment is the individual or couple; whole families usually not seen
best outcome is when spouses work together as a team

Unique aspects of the Bowen Family Therapy approach

focus on family history and avoiding replication of past negative patterns of interaction
use of the genogram
therapy and theory are consistent and inseparable
systemic in nature
controlled focus
cognitive orientation
effective with individuals or client families
Comparison with other theories
well established
strong emphasis on theory and practice
criticism that it is not gender sensitive
some research support
historical focus may encourage families to examine their history rather than the present
insight promoted before action
effective with clients and families experiencing severe dysfunction or low differentiation
the theory underlying the approach is its own paradigm
requires a large investment of time and money due to its long term structure
the number of people who can benefit from this type of therapy is limited

Key Terms

autonomy in Bowen theory a designation for the level of differentiation in a person which signals the ability to think through a situation clearly. In ethics, the right of individuals to make decisions and choices.

Bowen transmission process the passing of coping strategies and patterns of coping with stress from generation to generation

cutoff process by which members of a family avoid each other, either physically or psychologically, because of an unresolved emotional attachment.

detriangulation separating feelings from intellect.

differentiation of self the ability of persons to distinguish themselves from their family of origin at an emotional and intellectual level, as well as to balance the intrapsychic and interpersonal dimensions of self.

emotional reactivity feelings of overwhelm thinking, thus drowning out individuation.

fusion the merging of intellectual and emotional fucntions so that an individual does not have a clear sense of self and others.

genogram a visual representation of a person’s family tree depicted in geometric figures, lines, and words; originated by Bowen.

going home again a Bowenian technique in which the family therapist instructs the individual or family members with whom he or she is working to return home in order to better get to know the family in which they grew up. By using this type of information, individuals can differentiate themselves more clearly.

“I” position to make statements that express feelings and thoughts in a personal and responsible way that encourages others to express their opinions.

Nuclear family emotional process the emotional forces in families that operate over the years in recurrent patterns such as becoming disorganized or chaotic during a crisis.

transgenerational family therapy another term for Bowen family therapy.

triangle according to Kilpatrick (1980), it is the basic building block of any emotional system and the smallest stable relationsihp system

undifferentiated implies an emotional dependency on one’s family members, even if one is living away from them.

Classroom Discussion

1. You are working with a client family and begin to to assist them in developing a three generation family genogram. The claim for reimbursement that you file for this family is rejected by the managed care organization, which is refusing to pay for genograms. As a basis for filing an appeal of your claim, make a strong case for the value of genograms in therapeutic work.

Multiple Choice Questions

A genogram is a visual representation of a person’s family tree, going back at least three generations. It is useful in all the following ways except:
tracks relationship changes
shifts family members from clear cognitions to emotional reactivity
identifies repetitve patterns
demonstrates the impact of change and life cycle transitions
_____ is a frequent way of dealing with anxiety in which tension between two persons is projected onto another object.
1. family projection process
2. multigenerational transmission process
3. emotional cut off
4. triangulation
In Bowen Family Therapy, the term for patterns and strategies of coping with stress that are passed down from generation to generation is called:
1. transference
2. family projection process
3. Bowen transmission process
4. triangulation
The result of successful separation from your family of origin and distinguishing your rational and emotional selves is:
1. differentiation
2. emotional reactivity
3. emotional cut off
4. triangulation
Which theorist initiated the founding of the American Family Therapy Academy (AFTA)?
1. Murray Bowen
2. Nathan Ackerman
3. Salvador Minuchin
4. Jay Haley
According to Bowen, there are two counterbalancing forces: _____________ and ____________.
1. togetherness and sublimation
2. autonomy and triangulation
3. individuality and togetherness
4. freedom and responsibility
__________________ refers to statements that express feelings and thoughts in a personal and responsible way that encourages others to express their opinions.
1. Cutoff
2. “I” position
3. Emotional reactivity
4. Fusion
___________________ is the merging of intellectual and emotional functions so that an individual does not have a clear sense of self and others.
1. Compartmentalization
2. Reaction formation
3. Fusion
4. Differentiation of self
Individuals in a relationship who have low levels of differentiation have difficulty establishing ____________ because they have only a _________________.
1. intimacy; pseudo individuation / pseudo self
2. symbiosis; weak I-position
3. fusion; weak differentiation.
4. emotional reactivity; small cut-off
When Bowen family therapists are working to help people, especially couples, separate their feelings from their intellect, they are engaging in ______________________.
1. Fusion
2. Bifurcation
3. Detriangulation
4. Cutoffing
Which of the following statements is accurate regarding Bowen’s emphasis on sibling position?
1. Bowen, breaking with Adlerian tradition, indicated that sibling position had very little affect on individuals’personality characteristics and interpersonal functioning.
2. Bowen’s writings do not address sibling position, which seems to indicate he did not believe it influenced family systems or personality development.
3. Bowen suggested that people develop fixed personality characteristics based on their functional birth order in the family.
4. Bowen indicated that the more closely a marriage replicates a couple’s sibling positions in each person’s family origin, the more likely the couple would experience triangulation and dysfunction.
Which of the following, according to Bowen, occurs when a society experiences rapid population growth and/or steep economic decline?
1. Bowen did not have any opinion regarding macrosystems, as he was not a sociologist.
2. Bowen suggested that feedback loops within societies allowed these societies to deal effectively with such circumstances, so the society, as a whole, would remain in homeostasis.
3. Bowen theorized that societies either progress or regress. Thus, the factors indicated above would likely cause societal regression.
4. Bowen suggested that, although social regression was possible, it hasn’t occurred in human history since the middle ages.
Which one of the following statements reflects Bowen’s attitude toward asking questions?
1. Asking questions is the “magic bullet” and the main tool of therapy.
2. Asking questions is effective but, other methods, such as reflections and experiential activities, are more effective.
3. Asking questions leads to a power imbalance and disequilibrium in family systems which, in turn, create fusion.
4. The technique of asking questions can lead people to feel defensive and hurt, which creates a perfect breeding ground for pseudo-independence.
Which of the following statements reflect Bowen’s belief in discouraging emotional reactions to anxiety experienced in therapy?
1. Bowen therapists instruct family members to address each other directly as opposed to talking about someone through the therapist.
2. Bowen instructed family members to look at and talk to the counselor and not to each other.
3. Bowen instructed emotionally reactive family members to take a three day hiatus from the family in order to cool down.
4. None of the above.
Which of the following would be considered a goal of treatment in family counseling from a Bowenian perspective?
1. Family members will learn to be more present-focused, letting the past go and forging a mindful relationship in the here-and-now.
2. Family members will understand intergenerational patterns and gain insight into historical circumstances that have influenced the ways they presently interact.
3. Family members will learn the importance of being fused rather than becoming autonomous (i.e., selfish) and differentiated beings.
4. None of the above are goals of Bowen Family Therapy.
Which one of the following is true regarding the process of Bowen Family Therapy?
1. Bowen family therapists prefer to focus on the whole family, including working with extended family to help individuals understanding integenerational coping strategies.
2. The chief focus and place where change is emphasized is the individual or couple. The whole family is usually not seen.
3. For a family system to heal, multiple people, at least three, according to Bowen must change their fusive or undifferential tendencies and and move toward triangulation.
4. None of the above.

Essay Questions

Describe the role of the therapist in Bowenian Family Therapy.
Discus the anticipated outcomes of treatment with families in Bowenian Family Therapy. Be sure to apply key principles of Bowen Theory to your discussion of outcomes (e.g., role of fusion, differentiation).

Chapter 11

Behavioral and Cognitive-Behavioral Family Therapies

Chapter Overview

One of the oldest approaches in the helping professions
Began with a primary focus on behavior but has expanded to include cognitions
Behavioral family therapy began with parent-child problems and is based on social learning theory
Currently embraces a more interactional style of explaining and treating family behavior problems
Functional family therapy is a systemic type of behavioral family therapy
Cognitive-behavioral family therapy began in the 1970s and acknowledged the important role of cognitive factors (e.g., thoughts, beliefs) in causing and/or maintaining maladaptive behaviors

Major Theorists

B. F. Skinner

first to use the term behavior therapy
originated the concept of ‘operant conditioning’ (i.e., people learn through rewards and punishments to respond behaviorally in certain ways)

Gerald Patterson

primary theorist to apply behavior theory to family problems in the 1960s
primary rewards (e.g., candy, point systems, time-out, and contingent attention) used with parent-child problems
developed family observational codes to assess dysfunctional behavior
authored programmed workbooks for parents to help parents, children, and families modify behaviors
played a critical role in influencing other behaviorists to work from a systemic perspective with families
Neil Jacobson
strong research foundation, especially blending academic and clinical outcome research
research in 1995 revealed that 20% of male batterers have lower heart rates during times of physical assault
developed the concept of ‘acceptance’ or loving your partner as a complete person and not focusing on differences, as a strategy to promote change
prolific writer and workshop presenter

Premises of the theory

All behavior is learned and people act according to how they have been previously reinforced
Behavior is maintained by its consequences and will continue unless more rewarding consequences result from new behaviors
Maladaptive behaviors, not underlying causes, should be the targets of change
Primary concern is with changing present behavior, not dealing with historical developments
Assessment is ongoing throughout treatment
It is not necessary to treat the entire family
Behaviorists concentrate on teaching functional and appropriate new skills
Behavior therapy is not considered completely systemic but does have an emphasis on family rules and patterned communication processes
Social exchange theory (the rewards and costs of relationships) is viewed by some as the basis for a behavioral economy
Cognitive-behavioral theory holds that the relationship-related cognitions individuals hold, shape couple and family relationships
Health-promoting, relationship-related cognitions promote growth
Negative relationship-related cognitions lead to distress and conflict
Resistant in family members may be based on irrational beliefs

Types of behavioral and cognitive-behavioral family therapies

Therapies
more forms of treatment than any other approach, with the exception of strategic family therapy
Behavior Parent Training
also referred to as parent-skills training
goal is to change parents’ responses to a child or children, both through thoughts and actions
linear in nature
initial task is to identify and define a specific problem behavior, and its antecedents and consequences
parents are trained in social learning theory
didactic instruction and written materials utilized to change behaviors and thoughts
techniques include role playing, modeling, behavioral rehearsal, and prompting
problem behavior is charted throughout treatment
therapist rewards successful efforts through encouragement and praise
psychoeducational approaches are particularly effective for at-risk parenting behaviors
parents are trained in nonviolent resistance where the emphasis is on commitment and acceptance rather than control
Functional Family Therapy
all behavior is adaptive and serves a function
behaviors helps families achieve one of three interpersonal states

contact/closeness (merging)
distance/independence (separating)
combination of 1 and 2 (midpointing)

therapy is a three stage process

assessment

focuses on the function of the behavioral sequence

change

clarifying relationship dynamics
interrelating thoughts, feelings, and behaviors
interpreting functions of behaviors
relabeling behavior to reduce blame
discussing how change impacts the entire family
shifting treatment from the individual to the whole family

maintenance

educating the family
skills training for dealing with future difficulties, specifically communication, team building, and behavioral management (e.g., contracting)
Behavioral treatment of sexual dysfunctions
Masters and Johnson pioneered cognitive-behavioral approaches to working with couples in the treatment of sexual dysfunction in the late 1960s
Four phases of sexual responsiveness

excitement
plateau
orgasm
resolution

learning and behavioral techniques important tools in treating sexual dysfunctions
squeeze technique for treating premature ejaculation
teasing technique for treating performance anxiety
primary treatment is the conjoint therapy using a dual-sex therapy team
extensive sexual histories are taken
approach is systemic in orientation
Helen Singer Kaplan combined behavioral treatments with psychoanalytic techniques
couple sexual dysfunctions can stem from intrapsychic conflict, interpersonal couple conflict, and anxiety
Joseph LoPiccolo and associates report success with behavioral sex therapy techniques including
reduction of performance anxiety
sex education including the use of sexual techniques
skill training in communications
attitude change methodologies

Cognitive-Behavioral Family Therapy

similar to cognitive-behavioral therapy but broader and more extensive
cognitive treatment focus
modifying personal or collective core beliefs (i.e., schema)
teaching families to think for themselves and to think differently when it is helpful
behavioral treatment focus
expressive and listening skills used in communication
problem solving skills
negotiation and behavior change skills

Treatment techniques

positive reinforcement
extinction
shaping
desensitization
contingency contracts
cognitive/behavior modifications

General behavioral and cognitive-behavioral approaches

education
- attending lectures, reading books together, viewing videos as a group, having group discussion based on learning
communication and problem-solving strategies
- instruction, modeling, positive reinforcement
operant conditioning
mostly used in parent-child issues
teaches parents to use time-out and shaping procedures
contracting
used with families expressing severe levels of hostility
contracts build in rewards for behaving in a certain manner
Specific behavioral and cognitive-behavioral techniques
classical conditioning
a neutral stimulus is paired up with another event to elicit certain emotions through association
a person is associated with a gratifying behavior, such as a kind word or pat on the back
coaching
therapist helps families make appropriate responses by giving them verbal instructions and a chance to practice
contingency contracting
a written schedule or contract describing terms for trading or exchanging behaviors and reinforcers between two or more individuals
extinction
process of withdrawing previous reinforcers to return behavior to its original level
replacement behavior is positively reinforced
positive reinforcement
a material or social action that increases desired behaviors
for a reinforcer to be positive, the person must be willing to work for it
quid pro quo
something for something
often the basis for behavioral marital contracts
reciprocity
the likelihood that two people will reinforce each other at approximately equitable rates over time
marriage is often viewed as based on this principle
shaping
the process of learning in small, gradual steps
also referred to as ‘successive approximation’
systematic desensitization
dysfunctional anxiety is reduced or eliminated through pairing it with incompatible behavior, such as muscular or mental relaxation
gradual procedure
time-out
removal of persons from an environment in which they have been reinforced for certain actions
isolation for a limited amount of time results in the cessation of the targeted action
best accompanied by a retraining program where rewards are given if the undesirable behavior does not occur for an agreed-upon time period
job card grounding
used with adolescents and pre-adolescents
an age appropriate type of time-out
small household jobs are listed on index cards
when problem behavior occurs, the adolescent is given one of the jobs to complete and is grounded until the job is complete
grounding
used with adolescents where the person is removed from stimuli, thus limiting reinforcement from the environment
usually means the adolescent is required to attend school, perform household chores, and stay in his or her room unless eating meals, doing chores, or attending school
adolescents are not permitted to use the phone, watch television, use the computer (except for school work), have visitors, etc. until the job is completed or time has been served
charting
clients are asked to keep an accurate record of the problem behavior in order to establish a baseline (data on problem behavior before interventions are made)
from baseline data, interventions can be made to reduce the problem behavior
Premack principle
family members use high probability behavior (preferred behaviors) to reinforce low probability behavior (non-preferred behaviors)
family must first do less pleasant tasks before they are allowed to engage in pleasurable activities
disputing irrational thoughts
uses the ABC format (event, thought, emotion)
through disputing irrational thoughts, the couple or family will develop more rational thoughts and behaviors
thought stopping
used when a family member unproductively obsesses about an event or person
therapist has person engage in ruminating on a certain thought and interrupts the rumination by shouting “stop”
instruction is given for the person to interrupt the thought process internally
neutral or healthy thoughts replace the nonproductive or unhealthy thoughts
self-instructional training
focus on people instructing themselves in changing negative self-talk
self-statements help recall desirable behaviors or interrupt automatic behaviors
modeling and role playing
have family members act “as if” they were different
new behaviors are practiced and modeled
therapist gives feedback and correction as appropriate
“shame attack”
a family member does something he or she has dreaded and learns he or she is no worse off for having engaged in the activity (e.g., asking for something and not getting it)
family members can use ‘stress inoculation’ to break down potentially stressful events into manageable units and then to link all the parts together
Role of the therapist
therapist is the expert, teacher, collaborator, and coach
assists the family to identify dysfunctional behaviors and thoughts and works to set up behavior and cognitive-behavioral management programs
engages in modeling, giving corrective feedback, and teaching how to assess behavior and cognitive changes
Anatomy of Intervention Model (AIM)
introduction
assessment
motivation
behavior change
termination
therapist must be able to exhibit relationship skills such as warmth, humor, nonblaming, and self-disclosure
cognitive-behavioral therapists spend more time discussing issues with family members than do behavior therapists
therapists must have persistence, patience, knowledge of learning theory, and specificity in working with family members
Process and outcome
family members learn to identify, modify, change, or increase certain maladaptive behaviors and/or thoughts to increase functioning
behavioral family therapy focuses on parenting skills, positive family interactions, improving sexual behaviors
cognitive-behavioral family therapy is effective with family stress, adult sexual dysfunctions
blending of behavioral and cognitive-behavioral family therapies is common in practice
Unique aspects of behavioral and cognitive-behavioral approaches
emphases
use of learning theory
strong research orientation
approach has continued to evolve, expand, and incorporate new ideas
treatment is short term
focus is not on pathology (i.e., medical model)
ahistorical approach
assessment does not include looking for biological or chemical causes of behavior or cognition
Comparison with other theories
less systemic than other approaches
linear orientation may limit the introduction of a more complete family change process
no focus on the affective domain
lack of spontaneity and dependence on techniques may result in losing rapport with families
by not considering historical data, family patterns and dynamics may be misunderstood
family action is stressed over insight which may lead to change without understanding
integration of concepts and methods from other approaches may make cognitive-behavioral strategies appropriate as an adjunct to treatment when another approach is used

Key Terms

acceptance 1. Neil Jacobson’s term for loving your partner as a complete person and not focusing on differences. Such a strategy may promote change in couples. 2. the therapist’s personal and professional comfortableness with a family.

act as if a role-playing strategy where persons act as if they are the persons they want to be ideally.

Anatomy of Intervention Model (AIM) a cognitive-behavioral strategy where the therapist learns to play many roles and be flexible. It involves five phases: (1) introduction, (2) assessment, (3) motivation, (4) behavior change, and (5) termination.

baseline a recording of the occurrence of targeted behaviors before an intervention is made.

behavioral therapy the therapeutic approach that proposes that all behavior is learned and that people act according to how they have been previously reinforced. Behavior is maintained by its consequences and will continue unless more rewarding consequences result from new behaviors.

behaviorism a form of treating individuals where therapists focus on changing observable behaviors through such methods as reinforcement, extinction, and shaping.

charting a procedure that involves asking clients to keep an accurate record of problematic behaviors. The idea is to get family members to establish a baseline from which interventions can be made and to show clients how the changes they are making work.

classical conditioning the oldest form of behaviorism, in which a stimulus that is originally neutral is paired up with another event to elicit certain emotions through association.

cognitions thoughts.

cognitive behavior theory the idea that the cognitions individuals hold, shape how they think, feel, and behave.

cognitive behavior couple therapy an approach to working with couples that takes into account the impact of cognitions (i.e., thoughts) and behaviors on modifying couple interactions.

cognitive-behavioral family therapy an approach to working with families that takes into account the impact of cognitions (i.e., thoughts) and behaviors on modifying family interactions.

four phases of sexual responsiveness excitement, plateau, orgasm, and resolution.

functional family therapy a type of behavioral family therapy that is basically systemic.

parent-skills training a behavioral model in which the therapist serves as a social learning educator whose prime responsibility is to change parents’ responses to a child or children.

Premack principle a behavioral intervention in which family members must first do less pleasant tasks before they are allowed to engage in pleasurable activities.

schema core beliefs of an individual or couple.

shame attack a process within role playing where someone does something he or she has previously dreaded, for example, asking for an allowance. Individuals who use this technique find that when they do not get what they asked for, they are not worse off for having asked.

shaping the process of learning in small gradual steps; often referred to as successive approximation.

social exchange theory an approach that stresses the rewards and costs of relationships in family life according to a behavioral economy.

social learning theory a theory that stresses the importance of modeling and learning through observation as a primary way of acquiring new behaviors.

squeeze technique an approach used in sexual therapy in which a woman learns to stimulate and stop the ejaculation urge in a man through physically stroking and firmly grasping his penis.

stress inoculation a process in which family members break down potentially stressful events into manageable units that they can think about and handle through problem-solving techniques. Units are then linked so that possible events can be envisioned and handled appropriately.

successive approximation see shaping

teasing technique a sexual therapy approach in which a woman learns how to start and stop sexually stimulating a man.

Classroom Discussion

1. Behavioral and cognitive-behavioral family therapy do not focus on the affective domain. How does this limit the usefulness of the approach? How would you work with a client who focuses primarily in the affective domain?

2. What types of client problems might be best suited for these approaches? What client issues would not be appropriate for these approaches?

3. Conduct a role play in which the class attempts to identify the function of a behavioral sequence and then relabels the behavior to reduce blame.

Multiple Choice Questions

____________________ was the primary therapist to apply behavior theory to family problems in the 1960s.
1. B.F. Skinner
2. Gerald Patterson
3. Joseph LoPiccolo
4. Neil Jacobson
A basic premise of behavioral family therapy is
1. all behavior is learned
2. underlying causes should be the target of change
3. all family members must be treated
4. the importance of insight in the change process
An approach that stresses the rewards and costs of relationships in family life according to a behavioral economy is called:
1. shaping
2. social learning theory
3. social exchange theory
4. schema
All of the following are behavioral treatment techniques except:
1. positive reinforcement
2. tracking
3. extinction
4. contingency contracts
In ________________ people learn through rewards and punishments to respond behaviorally in certain ways.
1. classical conditioning
2. shaping
3. stress inoculation
4. operant conditioning
In _____, a neutral stimulus is paired up with another event to elicit certain emotions through association.
1. classical conditioning
2. shaping
3. stress inoculation
4. operant conditioning
A written schedule describing terms for trading or exchanging behaviors and reinforcers between two or more individuals is known as:
1. social exchange theory
2. quid pro quo
3. teasing technique
4. contingency contract
______________ spend more time discussing issues with family members than do ______________.
1. behavior parent training therapists; functional family therapists
2. cognitive-behavioral therapists; behavioral therapists
3. behavioral therapists; cognitive-behavioral therapists
4. sex therapists; play therapists
__________________ is an age appropriate type of time out for adolescents and preadolescents.
1. acceptance
2. shame attack
3. squeeze technique
4. job card grounding
Behavioral and cognitive-behavioral family therapy are focused on
1. the present
2. the past
3. the future
4. all of the above
_______________________ stresses the importance of modeling new behaviors.
1. social learning theory
2. social exchange theory
3. teasing technique
4. experiential theory
Jacobson defined ___________________ as loving one’s partner as a complete person and not focusing on differences.
1. operant interaction
2. classical relational aptitude
3. acceptance
4. schematic interpersonal being
Which of the following behavioral terms is defined as asking for what one wants?
1. desensitization
2. aggressiveness
3. assertiveness
4. autonomy
Which of the following is an example of intrapsychic conflict?
1. shame
2. marital discord
3. pressure to please
4. all of the above
Which of the following terms can be defined as personal or collective core beliefs?
1. Cognition
2. Schema
3. Squeeze
4. Abreaction
When a parent takes away previous reinforcers of an action so that a behavior returns to its original level, what behavioral technique is this parent employing?
1. Contingency contracting
2. Negative reinforcement
3. Quid pro quo
4. Extinction
Which of the following concepts involves the likelihood that two people will reinforce each other at approximately equitable rates over time?
1. Quid pro quo
2. Contingency contracting
3. Reciprocity
4. Operant conditioning
Which of the following involves learning in small, gradual steps?
1. Reciprocity
2. Shaping
3. Sytstematic desensitization
4. Operant conditioning
Which of the following terms depicts a process in which a person’s dysfunctional anxiety is reduced or eliminated through pairing it with incompatible behavior such as muscular or mental relaxation, a gradual process in which proressively higher levels of anxiety are treated one step at a time.
1. Shaping
2. Reciprocity
3. Systematic desensitization
4. Time-Out
__________________ is a behavior modification technique in which parents make a list of small chores that take 15 to 20 minutes to complete that are tasked to children or adolescents when a problem behavior begins. The adolescent is, therefore, grounded unitl the job is finished succesfully.
1. Time-Out
2. Job Card Grounding
3. Negative Reinforcement
4. Systematic Desensitization

Essay Questions

List and describe in detail three cognitive techinques you would use as a family therapist or which you would teach to parents to use with children. Be sure to describe what you appreciate about each technique and specific challenges these techniques would confront.
Describe two unique aspects of behavioral and CBT approaches.

Chapter 12

Experiential Family Therapy

Chapter Overview

Emerged out of the humanistic-existential psychology movement of the 1960s
Most popular in the early days of family therapy
Emphasis is on immediate, here and now, intrapsychic experience
Emphasis on affect (i.e., emotions) and awareness and expression of feelings

Major Theorists

Virginia Satir

social worker and teacher
one of the original members of the Mental Research Institute in Palo Alto, CA
known for a nurturing, warm, and genuine style
published Conjoint Family Therapy in 1964
strong and charismatic leader in the field
originator of family communications theory
utilized group family therapy
Satir’s model of family therapy is now called “communication/validation family therapy”

Carl Whitaker

psychiatrist
pioneering work with schizophrenics
utilized co-therapists to increase effectiveness
coauthored The Family Crucible with Augustus Napier
difficult to separate the therapist from the therapy
intuitive, spontaneous, and unstructured
major contribution was working with families in an uninhibited and emotional way
challenged people to gain control of their lives, examine their own view of reality, and live more fully in the present
Whitaker’s approach is called “symbolic-experiential family therapy”
“experience, not education . . . changes families”

Premises of the theory

Individuals are not aware of or suppress their emotions
Results in a climate of ‘emotional deadness’ where people avoid each other
Emphasis on expression of feelings and increased sensitivity
Focus is on the present
Concentration on increasing self-awareness by actively experiencing the here and now
Attachment theory is a major component of the experiential approach

Treatment Techniques

The effectiveness of this approach depends on the personhood of the therapist
Two groups of experiential family therapists
few techniques and a strong emphasis on use of self, spontaneity, and creativity (e.g., Whitaker)
use of highly structured activities congruent with the personality of the therapist (e.g., Satir and the majority of experiential therapists)

Therapists who use few techniques: Carl Whitaker

seven active interventions

redefine symptoms as efforts for growth
- - - helps families see previously unproductive behaviors as meaningful
model fantasy alternatives to real-life stress
- - - change may be fostered by going outside the realm of the expected or conventional
separate interpersonal stress and intra personal stress
- - - important to distinguish between them because there are often different ways of resolving them
add practical bits of intervention
- - - concrete and practical information may assist in making needed changes
augment the despair of a family member

enlarging or magnifying a family member’s feelings to increase understanding by other family members

promote affective confrontation

directing family members to examine their feelings before exploring their behaviors

treat children like children and not like peers

play with children and treat them in an age appropriate manner
Therapists who use structured techniques: Virginia Satir
- techniques are used to increase family members’ awareness and alter their relationships
- modeling of effective communication using “I” messages
  - replaces unclear and nonspecific messages with clear and direct personal positions
  - promotes leveling or congruent communication
  - Four communication roles that do not contribute to congruency

blamer is one who attempts to place the focus on others and not take responsibility for what is happening
placater is one who avoids conflict at the cost of his or her integrity
distracter is one who says and makes irrelevant statements that direct attention away from the issues being discussed
computer (or rational analyzer) is one who interacts only on cognitive or intellectual level and acts in a super-reasonable way
- sculpting

family members are placed into positions during the therapy session symbolizing the actual relationships as seen by one or more members
- - sculpting consists of 4 steps

setting the scene

therapist helps the sculptor identify a scene to explore
- - 1. choosing role players

individuals are chosen to portray family members
creating a sculpture
sculptor places each person in a specific metaphorical position spatially
processing the sculpture
sculptor and other participants derole and debrief about experiences and insights gained from the exercise

choreography
- family members are asked to symbolically enact a pattern or relational sequence similar to a “silent movie”
- reenact 2 to 3 times to increase depth of experience
- discuss what occurred and what family members would like to change
humor
- can be a risky intervention
- if successful, humor will reduce tension and promote insight
- if unsuccessful, humor may alienate some or all family members
- humor can be used to point out the absurdity of rigid positions or to relabel a situation to make it seem less serious
touch
- putting one’s arms around another, patting a person on the shoulder, shaking hands
- respect personal boundaries of clients
- represents care and concern but can be overdone or used inappropriately
props
- materials used to represent behaviors or to illustrate the impact of actions
- may be metaphorical or literal
- ropes, blindfolds
family reconstruction
- helps families discover dysfunctional patterns in their lives stemming from their families of origin
- reveals sources of old learning
- develops a more realistic picture of who their parents are as persons
- paves the way for family members to discover their own personhood
- begins with a “star” or “explorer” who maps out his or her family of origin in visual ways
- a “guide” (usually the therapist) helps develop a chronology of significant family events
- Three entry points or tools for a family reconstruction
  1. family map – a visual representation of the structure of three generations of the star’s family
  2. family life fact chronology – a listing of all the demographics and significant events
  3. wheel or circle of influence – a visual representation of those who have been important to the star and who have had an impact, positively or negatively on him or her
- star completes the exercise by working with a group of at least 10 people and enacting important family scenes

Other experiential techniques

play therapy
interventions that use play media as the basis for communicating and working with children
in child-centered play therapy, the therapist accepts the child with unconditional positive regard and allows the child complete freedom of expression
in experiential family therapy, play therapy is usually done within the context of a family session
filial therapy
an approach in which trained play therapists train parents to be therapeutic agents with their own children
techniques include didactic instruction, demonstration play sessions, at-home laboratory play sessions, and supervision
goal is to positively impact the parent-child relationship
strong research support
family drawings
joint family scribble
- each member makes a brief scribble, followed by the whole family incorporating their scribbles into a unified picture
- promotes awareness of what it is to work both individually and together
conjoint family drawing
- each family member draws a picture “as you see yourself as a family”
- each family member shares his or her drawing and perceptions that emerge are discussed
symbolic drawing of family life space
- therapist draws a large circle and instructs family members to include within the circle everything that represents the family and to place outside the circle everything those people and institutions that are not part of the family
- family is instructed to symbolically arrange themselves, through drawing, according to how they relate to each other
- family is asked to discuss what was drawn and why, as well as to share each members perspective on family dynamics and interactions
puppet interviews
- one of the family members is asked to make up a story using puppets
- acting out stories with puppets can help children feel safe enough to talk about what is happening in real life
- a variety of puppets is desirable
- works well with young children, shy children, or selectively mute children
- in actual practice, this technique is limited

Role of the therapist

therapist is an active participant
co-therapists increase effectiveness by allowing greater utilization of intuition
in Whitaker’s model, the therapist at times engages in spontaneous and absurd activities designed to raise emotion, anxiety, and insight and to break down rational defenses
in Satir’s model, the therapist is a facilitator and resource person who helps families understand themselves and others better and promotes clear communication
more structured experiential family therapists use props or other objects
in general, experiential family therapists
- establish a warm, accepting, caring, respectful, hopeful environment with an orientation toward change and improvement
- verbalize presuppositions of hope the family has
- help family members clarify goals and to use their natural abilities
- promote growth through stimulating experiences that provide opportunities for existential encounter
- behave as real, authentic people
- do not encourage projection or act as blank screens for families
- not only must have a commitment to the approach but must also be active risk-takers to be effective

Process and outcome

family members should become more aware of their own needs and feelings and share these impressions with others
more capable of autonomy and intimacy
treatment is designed to promote individual growth without an overriding concern for the needs of the whole family
some experiential family therapists insist on the whole family, preferably three generations, attending sessions
according to Whitaker, therapy consists of three stages
engagement is when the therapists become personally involved with their families through the sharing of feelings, fantasies, and personal stories
involvement is when therapists concentrate on helping the families try new ways of relating through the use of playfulness, humor, and confrontation
disentanglement occurs after families have made constructive changes and rules and roles have been modified
according to Satir, therapy consists of three stages
making contact (e.g., shaking hands, attending) to raise self-worth
chaos and disorder is when people are engaged in tasks, taking risks, sharing hurt and pain
integration and closure occurs as issues in stage two are worked on and family members are assisted to understand themselves and issues more thoroughly
the family is terminated when
transactions can be completed
family members can see themselves as others do
there is clear communication
family members can share openly and honestly and take responsibility for outcomes
primary goal of therapy is growth, sensitivity, the sharing of feelings, and congruence between inner experiences and outward behaviors
family must win the ‘battle for initiative,’ becoming actively involved and responsible for making changes
therapist must win the ‘battle for structure’ by setting up the conditions under which the therapy will proceed

Unique aspects of experiential family therapy

training programs set up for communication/validation family therapy (Avanta Network) and filial therapy (National Institute of Relationship Enhancement)
this approach is difficult to research but there is some evidence of the efficacy of Satir’s approach and for filial therapy
focus on immediate experiences
treatment tends to be of short duration and more direct than historical based approaches
emphasizes people as well as structures within the change process

Comparison with other theories

approach depends on sensitive and charismatic therapists
families are encouraged to participate physically in activities
focus on the present rather than on the past may keep therapists form dealing with historical patterns that need changing
individual growth and intrapersonal change is emphasized rather than family growth and interpersonal change
emphasis on the here and now without offering assistance about preparing themselves for the future

Key Terms

absurdity statements that are half-truths and even silly if followed to a conclusion. Whitaker and symbolic-experiential family therapists often work with families by using absurdities.

affect feelings or emotions.

Avanta Network an association that carries on the interdisciplinary work of training therapists in Satir’s methods.

battle for initiative the struggle to get a family to become motivated to make needed changes.

battle for structure the struggle to establish the parameters under which family therapy is conducted.

blamer according to Satir, a person who attempts to place blame on others and not take responsibility for what is happening.

choreography a process in which family members are asked to symbolically enact a pattern or a sequence in their relationship to one another. Choreography is similar to mime or a silent movie.

communication stance an experiential family therapy procedure of Satir’s in which family members are asked to exaggerate the physical positions of their perspective roles in order to help them “level.” See also leveling.

communication/validation family therapy a term often used to describe Virginia Satir’s model of working with families.

computer or rational analyzer according to Satir, a person who interacts only on a cognitive or intellectual level.

distractor according to Satir, a person who relates by saying and doing irrelevant things.

engagement the process where experiential therapists become personally involved with their families through the sharing of feelings, fantasies, and personal stories.

family life fact chronology a tool employed in family reconstruction in which the “star” creates a listing of all significant events in his or her life and that of the extended family having an impact on the people in the family.

family map a visual representation of the structure of three generations of the “star’s” family, with adjectives to describe each family member’s personality.

family reconstruction a therapeutic innovation developed by Satir to help family members discover dysfunctional patterns in their lives stemming from their families of origin.

filial therapy a hybrid form of child-centered play therapy in which parents (or other primary caregivers) engage in play therapy with their own child in order to address the child’s problem in the context of the parent/child relationship.

group family therapy seeing a number of unrelated families at one time in a joint family session

guide a family therapist who helps the star or explorer, during family reconstruction, chart a chronological account of family events that include significant events in the paternal and maternal families, and the family of origin.

humor an initiative and therapuetic procedure family therapists may use with families by pointing out the absurdity of their rigid positions or relabeling a situation to make it seem less serious.

“I” statements statements that express feelings in a personal and responsible way that encourages others to express their opinions.

leveling “congruent communication” in which straight, genuine, and real expressions of one’s feelings and wishes are made in an appropriate context.

placater according to Satir, a person who avoids conflict at the cost of his or her integrity.

play therapy a general term for a variety of therapeutic interventions that use play media such as toys as the basis for communicating and working with children.

props materials such as ropes and blindfolds used to represent behaviors or to illustrate the impact of actions.

sculpting an experiential family therapy technique in which family members are molded during the session into positions symbolizing their actual relationships to each other as seen by one or more members of the family.

self-worth Satir’s term that corresponds closely with self-esteem. Satir compared one’s feelings of self-worth to a pot. The fuller the pot is the more persons feels alive and have faith in themselves.

star or explorer a central character in family reconstruction who maps his or her family of origin in visually representative ways.

symbolic experiential therapy the name of the approach (sometimes also known as experiental symbolic therapy) given to Carl Whitaker’s theory of working with families.

symbolic drawing of family life space a projective technique in which the therapist draws a large circle and instructs family members to include within the circle everything that represents the family and to place outside of the circle those people and institutions not a part of the family. After this series of drawings, the family is asked to symbolically arrange themselves, through drawing, within a large circle, according to how they relate to one another.

wheel or circle of influence that circle of individuals who have been important to the star or explorer through family reconstruction.

Classroom Discussion

1. It is said that in Experiential Family Therapy, “the effectiveness of the approach depends on the personhood of the therapist.” What are the personality characteristics of a good experiential family therapist? Would you be a good fit for this approach? Discuss why or why not and give specific characteristics and rationale.

2. Discuss Carl Whitaker’s statement “experience, not education . . . changes families.”

3. What evidence is there for the effectiveness of this approach? How would you determine when termination is indicated? How would you measure success? What types of clients and/or client problems do you think would be suitable for experiential family therapy? What types of clients and/or client problems do you think would not be suitable?

Multiple Choice Questions

The major emphasis of experiential family therapy is:
behavior
interpersonal relations
affect and expression of feelings
irrational beliefs
Experiential family therapy is interested in exploring:
the past
the present
the past and the present
the future
The following theorist belongs to the group of experiential family therapists who practice with few techniques and a strong emphasis on self, spontaneity, and creativity:
1. Virginia Satir
2. Carl Whitaker
3. Peggy Papp
4. Fred and Bunny Duhl
In Satir’s communication roles, the _____ avoids conflict at the cost of his or her integrity.
1. blamer
2. placater
3. distracter
4. computer
A technique in experiential family therapy in which family members are physically placed into positions symbolizing actual relationships as seen by one or more members is called:
1. sculpting
2. choreography
3. use of props
4. family reconstruction
If successful, using _____ will reduce tension and promote insight. If unsuccessful, it may alienate some or all family members.
1. touch
2. props
3. choreography
4. humor
A tool used in family reconstruction is:
1. conjoint family drawing
2. sculpting
3. wheel or circle of influence
4. all of the above
The use of ____________ is thought to increase the effectiveness of treatment by allowing greater utilization of intuition.
1. humor
2. co-therapists
3. touch
4. education
Although their methods were different, Satir and Whitaker agreed that the primary goal of experiential family therapy is:
1. unlocking the past
2. educating the family
3. growth, sensitivity, and sharing of feelings
4. family growth and interpersonal change
_____________ is a general term for a variety of therapeutic interventions that use play media as the basis for communicating and working with children.
1. filial therapy
2. experiential therapy
3. child therapy
4. play therapy
Which of the following, according to experiential theory, is associated with not feeling or expressing emotions and results in the expression of symptoms such as avoidance within one or more family members.
1. Catharsis
2. Operant conditioning
3. Emotional deadness
4. “I” messages
Which of the following statements, according to experiential family therapy, occurs in dysfunctional families?
1. Family members speak in the first person, singular (i.e., I).
2. Family members speak in the first person, plural (i.e., we).
3. Family members speak in dialogic ways.
4. All of the above.
______________ refer(s) to congruent communication in which straight, genuine, and real expressions of one’s feelings and wishes are made in an appropriate context.
1. We language
2. I / thou statements
3. Object relations
4. Leveling
________________ is an individual who says and makes irrelevant statements that direct attention away from the issue and discussion.
1. Placater
2. Computer
3. Distractor
4. All of the above
In _____________________ family members are asked to symbolically enact a pattern or a sequence in their relationship to one another.
1. Choreography
2. Sculpting
3. Propping
4. Family reconstruction
_______________________, according to Satir, concentrates on revealing to family member the source of their old learning, enabling family members to develop a more realistic picture of who their parents are as persons, and setting up ways for family members to discover their respective personhoods.
1. Sculpting
2. Family reconstruction
3. Play therapy
4. Filial therapy
In which intervention are families given the instruction to draw a picture as they see themselves as a family?
1. Family sculpting
2. Family construction
3. Filial therapy
4. Conjoint family drawing

Essay Questions

Describe the role of the therapist in experiential family therapy.
Discuss the aspects of experiential family therapy that make it unique.

Chapter 13

Structural Family Therapy

Chapter Overview

Based on the experiences of Salvador Minuchin at the Wiltwyck School
Active and often aggressive family members resulted in the development of dramatic and active interventions for effectiveness
Continues to be a popular family therapy approach
Symptoms are best understood in the context of family interaction patterns
Changes in organization or structure must take place before symptoms can be relieved

Major Theorists

Salvador Minuchin

psychiatrist
wrote Families of the Slums based on his work at the Wiltwyck School
became the Director of the Philadelphia Child Guidance Clinic in 1965
developed a training program for paraprofessionals providing services to the poor
developed treatment techniques for psychosomatic families, particularly with anorectics
wrote Families and Family Therapy, a clearly written and influential book
prolific writer and workshop presenter
Premises of the theory
pragmatic
every family has a structure that organizes the ways in which family members interact
family structure is revealed only when the family is in action
emphasis on the whole family and its subunits
‘coalitions’ are alliances between specific family members against a third
‘stable coalitions’ are fixed and inflexible unions that become a dominant part of the family’s everyday functioning
‘detouring coalitions’ occur when the pair holds a third family member responsible for their difficulties or conflicts with one another, thus decreasing stress on themselves or their relationship
the family is the unit of treatment
‘subsystems’ are smaller units of the system as a whole and exist to carry out the tasks of the family
spousal subsystem is composed of the marriage partners and works best when there is complementarity of functions
parental subsystem is made up of those responsible for the care, protection, and socialization of the children and works best in a cohesive and collaborative manner
parental subsystems change as children grow
cross-generational alliances contain members of two different generations and may involve collusion to obtain certain objectives or needs, such as love or power
sibling subsystem contains members of the same generation
‘boundaries’ are the physical and psychological factors that separate people from one another and organize them
‘clear boundaries’ are rules and habits that enhance clear communication and relationships
‘rigid boundaries’ are inflexible and keep people separated from each other, making it difficult to relate in intimate ways, and may result in emotional detachment from other family members
‘diffuse boundaries’ do not have enough separation among family members and encourage dependence
a ‘parentified child’ is one who is given responsibilities and privileges that exceed what would be developmentally consistent with his or her age
therapists must be careful to not mistake normal family development and ‘growing pains’ for pathological patterns
‘alignments’ are ways that family members join together or oppose one another in carrying out family activities
‘roles’ are prescribed and repetitive behaviors involving a set of reciprocal activities with other family members or significant others; behaviors family members expect from each other and themselves
‘rules’ are implicit or explicit guidelines that determine behaviors of family members and may be adhered to regardless of changes in the family
‘power’ is the ability to get something done and is related to authority and responsibility
‘dysfunctional sets’ are the repetitive family reactions to stress, repeated without modification

Treatment techniques

two general types of techniques, those used in establishing a therapeutic alliance and those focused on the change process
joining
therapist makes contact with the family, expressing interest in each member
therapist takes a leadership role in initiating the treatment process
important to join with powerful as well as angry family members
four techniques of joining
1. ‘tracking’ is when the therapist follows the content of the family, uses open ended questions, is nonjudgmental, and give objective feedback
2. ‘mimesis’ is when the therapist adjusts the manner or content of his or her communications to become more like the family
3. ‘confirmation’ of a family member occurs when the therapist uses an affective word to reflect an expressed or unexpressed feeling of a family member; also may involve a nonjudgmental description of the behavior of a family member
4. ‘accommodation’ is how a therapist joins the family by making personal adjustments in order to achieve a therapeutic alliance
Disequilibrium techniques
techniques aimed at changing a system by creating a different interactional sequence and producing a different perspective of reality
‘reframing’ is used to change a perception by explaining a situation from a different context; helpful in helping negative situations to be viewed more favorably and to promote movement
‘punctuation’ involves the therapist selectively describing or highlighting a transaction as a means of changing the perception of everyone involved
‘unbalancing’ is a procedure in which the therapist temporarily supports an individual or subsystem against the rest of the family, forcing the rest of the family to respond differently and expand their roles and functions
‘enactment’ brings the action into the therapy room by asking family members to show the therapist how they interact during problematic behavioral sequences; redirects communication among family members instead of between the family and the therapist
working with spontaneous interaction focuses attention on a particular behavior, allowing the therapist to point out the dynamics and sequences and to focus on process not content
boundary making helps the family define, redefine, or change the boundaries within the family
‘intensity’ involves the use of strong affect, repeated interventions, or prolonged pressure to change maladaptive behaviors
‘restructuring’ is the process of altering existing hierarchical and interactive patterns to increase family functioning and symptom reduction; accomplished through enactment, unbalancing, directives, and boundary making
‘shaping competence’ is when the therapist reinforces family members for doing things right or making their own appropriate decisions
‘diagnosing’ is a proactive method to describe and/or map out the systemic interrelationships of all family members; usually done early in the therapeutic process
‘adding cognitive constructions’ supplements action oriented techniques by using words, such as advice or information, to help families help themselves.
‘pragmatic fictions’ are pronouncements that help families change
‘paradox’ is a technique in which a confusing message is sent to the family designed to frustrate or confuse them and provide them motivation to search for alternatives

Role of the therapist

observer
expert
active and directive
requires high energy and precise timing
therapist role changes over the course of therapy
first phase – therapist joins the family and takes a leadership position
second phase – therapist maps out the underlying family structure
final phase – therapist helps transform the family structure
assumes responsibility for setting up and directing therapeutic activities and interventions
therapist is never a ‘player’ in the family interactions, but works to change the family structure without becoming a part of it

Process and outcome

process of change is gradual but steady
successful treatment results in symptom resolution and structural change
action is emphasized over insight
‘homework’ is given for activities outside the sessions to practice new behaviors
family members learn to relate to one another in more functional and productive ways
dated and outgrown rules are replaced
parents are placed in charge of children
differentiation among distinct subsystems occurs
goal is structural change

Unique aspects of structural family therapy

a versatile approach applicable in many situations, especially with juvenile delinquents, alcoholics, anorexics, low SES families, minority and cross-cultural populations
sensitive to the effect of culture on families
strong emphasis on terminology and ease of application
structural family therapy helped family therapy become accepted in the medical and psychiatric communities
strong emphasis on symptom removal and family reorganization
pragmatic focus on problem-solving
active therapist involvement in bringing about change

Comparison with other theories

structural family therapy is a well-developed, action-oriented and pragmatic approach
as well articulated and illustrated as any other family therapy
criticized for being too simple and lacking complexity
criticized for being sexist and reinforcing sexual stereotypes
focus on the present with no emphasis on past patterns or family history
sometimes difficult to distinguish from strategic family therapy
focus on process, not content
therapist takes a great deal of responsibility for initiating change
short time frames for treatment
may limit family empowerment because the therapist is active and in control of the process

Key Terms

adding cognitive constructions the verbal component of structural family therapy, which consists of advice, information, pragmatic fictions, and paradox.

alignments the ways family members join together or oppose one another in carrying out a family activity.

boundaries the physical and psychological factors that separate people from one another and organize them.

clear boundaries rules and habits that allow and encourage dialogue and thus help family members to enhance their communication and relationships with one another.

coalition an alliance between specific family members against a third member. See also detouring coalition; stable coalition.

complementarity the degree of harmony or reciprocity in the meshing of family roles.

confirmation of a family member a process that involves using a feeling word to reflect an expressed or unexpressed feeling of that family member or using a nonjudgmental description of the behavior of the individual.

cross-generational alliance (coalition) an inappropriate family alliance that contains members of two different generations within it, for example, a parent and child collusion.

detouring coalition a coalition in which a pair holds a third family member responsible for their difficulties or conflicts with one another.

diagnosing a proactive structural family therapy technique where the systematic interrelationships of all family members is described early in the treatment process.

diffuse boundaries arrangements that do not allow enough separation between family members, resulting in some members becoming fused and dependent on other members.

dysfunctional sets are the family reactions, developed in response to stress, that are repeated without modification whenever there is family conflict. For example, one spouse might verbally attack the other, bringing charges and countercharges, until the fight escalates into physical violence or the couple withdraws from each other.

enactments the actions of families that show problematic behavioral sequences to therapists, for example, having an argument instead of talking about one.

Institute for Family Counseling an early intervention program at the Philadelphia Child Guidance Center for community paraprofessionals that proved to be highly effective in providing mental health services to the poor.

intensity the structural method of changing maladaptive transactions by having the therapist use strong affect, repeated intervention, or prolonged pressure with a family.

mimesis a way of joining in which the therapist becomes like the family in the manner or content of their communications—for example, when a therapist jokes with a jovial family.

parental subsystem the subsystem made up of those responsible for the care, protection, and socialization of children

pragmatic fictions pronouncements that help families and family members change, such as when a therapist tells children that they are acting younger than their years.

punctuation the way a person describes a situation, that is, beginning and ending a sentence, due to a selective perception or emotional involvement in an event.

reframing a process in which a perception is changed by explaining a situation from a different context. Reframing is the art of attributing different meaning to behavior.

rigid boundaries inflexible rules and habits that keep family members separated from each other.

roles prescribed and repetitive behaviors involving a set of reciprocal activities with other family members or significant others; behaviors family members expect from each other and themselves.

rules implicit or explicit guidelines that determine behaviors of family members.

shaping competence the procedure in which structural family therapists help families and family members become more functional by highlighting positive behaviors.

sibling subsystem that unit within the family whose members are of the same generation, for example, brothers and sisters. The concept of sibling position is important in both Adlerian and Bowen family therapy.

spousal subsystem the subsystem composed of marriage partners

stable coalition a fixed and inflexible union (such as that of a mother and son) that becomes a dominant part of a family’s everyday functioning.

structural family therapy’s major thesis a thesis stating that an individual’s symptoms are best understood when examined in the context of family interactional patterns. A change in the family’s organization or structure must take place before symptoms can be relieved.

structure an invisible set of functional demands by which family members relate to each other.

tracking a way of joining in which the therapist follows the content of the family (i.e., the facts). triangulating projecting interpersonal dyadic difficulties onto a third person or object (i.e., a scapegoat).

unbalancing therapeutically allying with a subsystem. In this procedure, the therapist supports an individual or subsystem against the rest of the family.

Classroom Discussion

1. Structural family therapy was developed during Salvador Minuchin’s time at the Wiltwyck School, a residential facility with active and often aggressive residents and family members. Because of these origins, interventions are often active, dramatic, and intense. Discuss this unique approach to family therapy and, in particular, what is meant by structural family therapists who state “family structure is only revealed when the family is in action.”

2. In this approach, the therapist takes a leadership role in initiating the treatment process. It is crucial to join with everyone, especially powerful as well as angry family members. What is the rationale behind the need to join in this way and what might you say or do to accomplish this?

3. In describing the role of the therapist in structural family therapy, the therapist should never be a ‘player’ in the family interaction, but instead works to change the family structure without becoming a part of it. Discuss how this can be done and why it is important to not become a part of the family structure.

Multiple Choice Questions

In order to highlight and modify interactions in the family, structural therapists must use intensity to
1. interrupt rigid patterns of conflict-avoidance
2. break families loose from their patterns of equilibrium
3. extend interactional sequences beyond the point where dysfunctional homeostasis is reinstated
4. all of the above
"Unbalancing" involves
1. realigning relationships between subsystems
2. therapeutic neutrality
3. restorying the family's narrative
4. taking sides
Boundaries are physical and psychological factors that separate people from one another and help organize them. The healthiest boundaries are:
1. clear
2. rigid
3. diffuse
4. stable
Subsystems may be all the following EXCEPT:
1. spousal
2. sibling
3. cross-generational
4. parental
_______________ are ways that family members join together or oppose one another in carrying out family activities.
1. enactments
2. dysfunctional sets
3. pragmatic fictions
4. alignments
There are four techniques for ‘joining’ with family members. In which technique does a make personal adjustments in order to achieve a therapeutic alliance?
1. tracking
2. mimesis
3. confirmation
4. accommodation
The technique of changing a perception by explaining a situation from a different context is called:
1. enactment
2. pragmatic fictions
3. reframing
4. restructuring
The structural family therapy approach has a focus on:
1. the present
2. the past
3. the future
4. all of the above
In the structural approach to working with families, the focus is on _____, not _____.
1. content; process
2. process; content
3. discussion; action
4. action; discussion
An alliance between specific family members against a third member is called a(n):
1. rigid boundary
2. alignment
3. coalition
4. dysfunctional set
_____________________, according to Minuchin, is an invisible set of functional demands that organizes the ways in which family members interact.
1. Family constellation
2. Family paradigm
3. Family structure
4. None of the above
___________________ is an alliance in which the pair holds a third family member responsible for their difficulties or conflicts with one another, thus decreasing the stress on themselves or their relationship.
1. Stable coalition
2. Established coalition
3. Triangulate
4. Detouring coalition
A grandfather, Jack, is responsible for the care of his grandson, Tim. This would constitute which type of system in structural family theory?
1. Parental
2. Couple
3. Spousal
4. Cross-generational
Which of the following contains members of two different generations within it?
Parental subsystem
Cross-generational alliance (coalition)
Sibling subsystem
Grand subsystem
In which type of boundary is there not enough separation between family members, which can create fusion?
1. Rigid
2. Clear
3. Fused
4. Diffuse
Which of the following is a system process in which children become involved in parents’ conflictual interactions by taking sides, distracting parents, and carrying messages to avoid or minimize conflict between parents?
1. Diffuse boundaries
2. Triangulation
3. Fusion
4. All of the above
_________________ is the process of coupling that occurs between the therapist and the family, leading to the development of the therapeutic system.
1. Fusing
2. Triangulation
3. Joining
4. Splitting
In which technique do therapists ally with a subsystem to support an individual or subsystem against the rest of the family?
1. Unbalancing
2. Balancing
3. Enactment
4. Punctuation
___________________ is the structural method of changing maladaptive transactions by using strong affect, repeated intervention, or prolonged pressure.
1. Enactment
2. Unbalancing
3. Punctuation
4. Intensity
__________________ is a confusing message meant to frustrate or confuse families and motivate them to search for alternatives.
1. Pragmatic fictions
2. Paradox
3. Disequilibrium
4. None of the above

Essay Questions

What is the role of the therapist in structural family therapy?
Describe how a structural family therapist would view positive outcomes.

Chapter 14

Strategic Family Therapies

Chapter Overview

Influenced by the work of Milton Erickson
Treatment goal is change
Strategy for each specific problem
Insight and history are not part of treatment
Two major variations

Mental Research Institute
Family Therapy Institute of Washington, DC

Strategic Family Therapy

Goal is to change behavior by manipulating it and not to instill insight
Milton Erikson’s approach had three major facets

accepting and emphasizing the positive
using indirect and ambiguously worded directives
encouraging or directing routine behaviors so that resistance is exhibited through change rather than through normal and continuous actions

Major theorists

Jay Haley
masters in communication
worked with and influenced by Gregory Bateson, Milton Erickson, and Salvador Minuchin
joined Mental Research Institute (MRI) staff
adapted Erikson’s individual approach to work with families
first editor of Family Process
established the Family Therapy Institute of Washington, DC with Cloe Madanes in 1974
prolific writer, trainer, supervisor, and workshop presenter
influential books include Problem Solving Therapy in 1976 and Leaving Home in 1980
Cloe Madanes
raised in Argentina
read Freud; majored in psychology
worked as a research assistant for Paul Watzlawick at the Mental Research Institute
worked as a clinician in a large mental hospital in Argentina
employed by Salvador Minuchin at the Philadelphia Child Guidance Clinic
attracted to strategic family therapy
married Jay Haley
opened up Therapy Institute of Washington (D.C.) with Haley
innovator of strategic practices including the pretend technique
used gentler approach to strategic family therapy than Haley
created unique and powerful techniques for working with sexual offenders

Premises of the theory

short term treatment of about 10 sessions with focus on change
focus on solutions, often opposite of what has been attempted before
‘family rules’ are the overt and covert rules families use to govern themselves
‘family homeostasis’ is the tendency for families to stay in the same patterns of functioning unless challenged to change
‘quid pro quo’ refers to the responsiveness of family members to treat each other in the way they are treated; something for something
‘redundancy principle’ is the fact that a family interacts within a limited range of repetitive behavioral sequences
‘punctuation’ refers to a belief that people in a transaction believe that what they say is caused by what others say
‘symmetrical relationships and complementary relationships’ highlight the fact that relationships within a family are both symmetrical (among equals) and complementary (among unequals)
‘circular causality’ is the idea that one event does not “cause” another but that events are interconnected and factors behind behavior are multiple

Treatment techniques

techniques are very innovative
not helpful to tell families what they are doing wrong
behavior change must precede changes in feelings and perceptions
interventions are tailored to fit each family
‘reframing’ is the use of language to bring about a cognitive shift and alter the perception of the situation
‘directives’ are instructions from the family therapist for the family to behave differently
nonverbal messages (e.g., silence, voice tone, posture)
direct and indirect suggestions (e.g., “go fast” or “you may not want to change too quickly”)
assigned behaviors (e.g., when you think you won’t sleep, force yourself to stay up all night)
directives increase the influence of the therapist in the change process
‘paradox’ is a controversial and powerful technique and has several variations
‘prescribing the symptom’ is giving the family permission to do something they are already doing in order to decrease resistance
‘restraining’ is when the therapist tells the family they are not capable of changing
‘prescribing’ is instructing the family to enact a problem behavior in front of the therapist
‘redefining’ is attributing positive connotations to problem behaviors
‘ordeals’ help clients to give up symptoms that are more troublesome to maintain than they are worth
the ordeal is a constructive or neutral behavior that must be performed before engaging in the undesirable behavior
the goal is for the client to give up the symptomatic behavior in order to avoid performing the constructive behavior
‘pretend’ is when family members are asked to pretend to engage in problem behavior, helping them to change through experiencing control of previously involuntary action
‘positioning’ involves the therapist accepting and exaggerating what the family is saying to help the family see the absurdity of what they are doing

Role of the therapist

active, flexible and creative
therapist is responsible for planning strategies to solve problems
“symptom focused and behaviorally oriented”
first task is to define a presenting problem in such a way that it can be solved
problem is defined as one the family has control over and that involves a power struggle
essential to make changes within the first three sessions
each case is handled uniquely
extensive use of homework

Process and outcome

goal is to resolve, remove, or ameliorate the problem the family agreed to work on
families learn how to address other problems in a constructive manner
four common procedures for successful outcomes
defining a problem clearly and concisely
investigating all solutions that have been previously tried
defining a clear and concrete change to be achieved
formulating and implementing a strategy for change
emphasis on process rather than content
focus on breaking up ‘vicious cycles’ of interaction and replacing them with ‘virtuous cycle’ that highlight alternative ways of acting

Unique aspects of strategic family therapy

flexible approach that works well with a variety of client families
effective in cases of enmeshment, eating disorders, and substance abuse
the entire system does not have to be involved in treatment
emphasis on innovation and creativity
works well in combination with other therapies, including behavioral, and structural approaches

Comparison with other theories

concentrates on one problem and helps focus family resources quickly and efficiently
criticized for being too “cookbookish’ and ‘mechanical’
existence of schizophrenia is not acknowledged by Jay Haley
strategic family therapy requires considerable training and skills to implement some of its methods
short term nature may not adequately address the seriousness or extent of problems
lack of collaborative input from client families
therapist takes the blame if treatment does not produce the desired results

Milan Systemic Family Therapy

also known as the Milan approach
stresses the interconnectedness of family members and second-order change
Major theorist
Mara Selvini Palazzoli
native of Italy, trained as a psychoanalyst
was frustrated by results of her work with patients who had eating disorders
along with other systems-minded psychiatrists founded the Center for the Study of the Family in Milan, where they developed the Milan model
continued studying family systems after Milan team split up in 1980
described her client-families as engaged in a series of games, which serve to stabilize and benefit family members
Premises of the theory
therapists take a circular view of problem maintenance and a planned orientation to change
a family’s symptoms serve as a “thermometer” of sorts, revealing the relational health of the family
focus of therapy is on family communication patterns and conflict between competing hierarchies
therapists maintain therapeutic neutrality, which allows them to assess family dynamics without losing objectivity and without assuming the family’s responsibility for generating its own problem solutions
Treatment techniques
paradox, in which the therapist indirectly challenges the family’s view of its current situation and suggests opportunity for change
hypothesizing, in which the therapeutic team formulates hypotheses regarding a family’s symptoms prior to the family’s first session and as therapy continues and the therapeutic team has additional information about the family
positive connotation, in which the therapist positively reframes a family’s or family member’s behavior
circular questioning, used by the therapist to expand family members’ perceptions
invariant/variant prescriptions, used by the therapist to break up power struggles and encourage healthy boundaries by the parent(s)
rituals, used by the therapist to create new behaviors and new perceptions within the family
Role of the therapist
therapists is both expert and “co-creator”
takes a nonblaming stance, is neutral
gives directives
is not trying to overtly change the family, but is in essence challenging families to consider new behaviors and new perceptions
Process and outcome
10 or fewer sessions
family members are able to see how their behaviors affect one another
family members realize their interconnectedness and shared responsibility for problem-solving
family members create new, more effective behaviors and perceptions
families are equipped to sustain new, improved functioning
Unique aspects of systemic therapy
Emphases
systemic family therapy is flexible and effective with many family types dealing with many types of issues
therapists employ a team approach to working with families, which is expensive but effective
Peggy Papp is an example of a therapist who has successfully utilized multiple team members in systemic family therapy
focuses on one problem over a short period of time as a way of helping families gain momentum in their efforts toward change
Comparison with other theories
Milan approach more accepted in Europe and used less elsewhere due to its nonintervention roots
espouses a controversial view of schizophrenia
tailors interventions to the unique therapeutic needs of a family

Key Terms

assigned behaviors a strategic therapy technique where clients are asked to perform certain actions such as staying up when they begin to feel sleepy.

circular causality the idea that one event does not “cause” another, but that events are interconnected and that the factors behind a behavior, such as a kiss or a slap, are multiple.

direct and indirect suggestions a technique used in strategic family therapy that is a part of a usually purposefully ambiguous but important message to a client family such as “go slow” or “you may not want to change too quickly.”

directive an instruction from a family therapist for a family to behave differently. A directive is to strategic therapy what the interpretation is to psychoanalysis—that is, the basic tool of the approach.

family rules the overt and covert rules families use to govern themselves, such as “you must only speak when spoken to.”

games negative family behaviors that stabilize and benefit families

homeostasis the tendency to resist change and keep things as they are, in a state of equilibrium.

Milan approach another term for systemic family therapy, stresses interconnectedness of family members while emphasizing the importance of second-order change in families

ordeal a technique in which a therapist assigns a family or family member(s) the task of performing a specific activity (i.e., an ordeal) any time the family or individuals involved display a symptom they are trying to eliminate. The ordeal is a constructive or neutral behavior (e.g., doing exercise), but disagreeable to the person directed to engage in it.

positioning acceptance and exaggeration by the therapist of what family members are saying. If conducted properly, it helps the family see the absurdity in what they are doing.

positive connotation a type of reframing in which each family member’s behavior is labeled as benevolent and motivated by good intentions.

prescribing a strategic family therapy technique in which family members are instructed to enact a troublesome dysfunctional behavior in front of the therapist and to work it out past the point where they usually get stuck.

prescribing the symptom a type of paradox in which family members are asked to continue doing as they have done. This technique makes families either admit they have control over a symptom or give it up.

pretend technique a technique originated by Cloe Madanes in which the therapist asks family members to pretend to enact a troublesome behavior, such as having a fight. Through this procedure, individuals transform an involuntary action into one that is under their control.

punctuation the way a person describes a situation, that is, beginning and ending a sentence, due to a selective perception or emotional involvement in an event.

quid pro quo literally, something for something.

redefining a stratgic family therapy technique of attributing positive connotations to symptomatic or troublesome actions. The idea is that symptoms have meaning for those who display them, whether such meaning is logical or not. Redefining is one way of lowering resistance.

redundancy principle the fact that a family interacts within a limited range of repetitive behavioral sequences.

reframing a process in which a perception is changed by explaining a situation from a different context. Reframing is the art of attributing different meaning to behavior.

restraining a type of paradox where therapists tell a client family that they are incapable of doing anything other than what they are doing. The intent is to get the family to show they can behave differently.

rituals specialized types of directives that are meant to dramatize significant and positive family relationships or aspects of problem situations.

strategic therapy a term coined by Jay Haley to describe the therapeutic work of Milton Erickson in which extreme attention was paid to details of client symptoms and the focus was to change behavior by manipulating it and not instilling insight.

therapeutic neutrality, or neutrality the therapist’s stance that allows him/her to assess family dynamics without losing objectivity or taking responsibility for the family’s problem-solving efforts

Classroom Discussion

1. Paradoxical interventions are controversial and powerful techniques used by strategic family therapists in the change process. What are these interventions and what makes them so controversial? Take a position for or against the use of paradox and defend your position.

2. In strategic family therapy, the therapist is responsible for planning strategies to resolve problems. How does this therapist’s role differ from other approaches you have studied? What are the conditions necessary for therapists to feel comfortable with the level of responsibility called for in this model? What do you think about assuming this level of responsibility?

3. Explain why it is important to highlight differences among family members and give some examples of how you

might do this as a strategic family therapist.

4. Compare and contrast strategic family therapy and Milan systemic family therapy, paying particular attention to theoretical underpinnings, role of the therapist, techniques, and process and outcome.

Multiple Choice Questions

Strategic family therapy has been strongly influenced by the work of:
1. Murray Bowen
2. Milton Erikson
3. David Espston
4. Virginia Satir
Goals in strategic family therapy include all the following EXCEPT:
1. behavior change
2. symptom removal
3. breaking up vicious cycles of interaction
4. instilling insight
In strategic family therapy, instructions from the therapist for the family to behave differently are called
1. ordeals
2. hypothesizing
3. invariant prescriptions
4. directives
An example of a paradoxical technique would be:
1. homework
2. prescribing the symptom
3. positive connotation
4. positioning
A strategic family therapy technique with a goal for the client to give up symptomatic behavior in order to avoid performing a constructive behavior is known as:
1. restraining
2. prescribing
3. ordeal
4. pretending
A method of interviewing in which questions are asked to highlight differences among family members is known as:
1. a therapeutic double bind
2. circular questioning
3. positive connotation
4. a family ritual
The reason that strategic and structural family therapy overlap is due to _______ who worked in both strategic and structural family therapy environments.
1. Paul Watzlawick
2. Selvini Palazzoli
3. Cloe Madanes
4. Jay Haley
Strategic family therapy has been found to be successful in treating families and their members who display such dysfunctional behaviors as ______
1. enmeshment
2. eating disorders
3. substance abuse
4. all of the above
The strategic family therapist works as an expert and is overtly active believing that it is essential to make changes in people and families within the first _____ sessions.
1. two
2. three
3. four
4. five
Strategic family therapists believe that families interact within a limited range of repetitive behavioral sequences known as the ________ principle.
1. neutrality
2. family dance
3. redundancy
4. redefining
Directing parents to go out together for various periods of time without telling their children where they are going and when they will return is an example of what technique?
1. paradox
2. homework
3. variant prescription
4. invariant prescription
Therapeutic neutrality means that the therapist does which of the following?
1. takes an active role in the therapy
2. joins with the family
3. encourages family members to generate solutions to their own problems
4. reframes negative communication
Brief therapy has more to do with ____________ than with ________________.
1. time; clarity about what needs to be changed
2. clarity about what needs to be changed; time
3. the length of individual sessions; the amount of sessions
4. the amount of sessions; the length of individual sessions
__________________ is the tendency of the family to remain in its same pattern of functioning unless challenged to do otherwise.
1. Redundancy principle
2. Punctuation
3. Family homeostasis
4. Circular casuality
Which of the following represents the idea that one event does not “cause” another, but that events are interconnected and that, the factors behind a behavior, such as a kiss or a slap, are multiple?
1. Punctuation
2. Redundancy
3. Homeostasis
4. Circular casuality
In this technique, the therapist tells the client-family that they are incapable of doing anything other than what they are doing.
1. Prescribing
2. Restraining
3. Redefining
4. All of the above
In this technique, a therapist accepts and exaggerates what family members are saying.
1. Pretending
2. Positioning
3. Prescribing
4. Redefining

Essay Questions

What are the main roles of a strategic family therapist?
Describe the unique aspects of strategic family therapy.

Chapter 15

Solution-Focused Brief Therapy

Chapter Overview

Solution-Focused Family Therapy

Major theorists

Steve deShazer
studied with Milton Erickson
began his career at the Mental Research Institute
established the Brief Family Therapy Center in the late 1970s
an ecosystemic approach that uses a team approach whenever possible
team members are called ‘consultants’
died in 2005
Insoo Kim Berg
born into a prosperous Korean family
learned through Korean War to value people over things
married Steve deShazer
served as Executive Director of the Brief Family Therapy Center
founder of the Solution-Focused Brief Therapy Association
author or co-authored 10 books on solution-focused therapy
died in 2007
Bill O’Hanlon
trained as a family therapist
studied with Milton Erickson
influenced by Erikson, he shifted attention from problems to solutions
approach now called ‘possibility therapy’
pragmatic approach
Michele Weiner-Davis
bachelors degree from Grinnell; social work masters from Kansas
marital & family therapist outside Chicago
author of Divorce Busting, Keeping Love Alive and other popular books
set up Divorce Busting Center in Boulder, Colorado
a popular media personality/professional
Premises of the theory
based on social constructionism (i.e., knowledge is time- and culture-bound)
treatment includes social, historic, and cultural contexts of families/persons
reality is not objective but a reflection of observation and experience
language influences the way people see the world
there is no absolute truth; all meaning is constructed
dysfunctional families get stuck in repetitive, unproductive attempts to solve their problems
solution-focused family therapy breaks up repetitive nonproductive behavior patterns and sets up situations with a more positive view and active participation in doing something different
causal factors are not important
identifying problems from non-problems is important
exceptions to problem behavior are emphasized
all families have resources and strengths to resolve complaints
treatment is short term
history is not emphasized
all families want to change
only a small amount of change is necessary

Treatment techniques

treatment is collaborative with clients
primary technique is to co-create a problem with a family that they want to solve
set up a hypothetical solution by asking the ‘miracle question’ (“If a miracle happened tonight and you woke up tomorrow and the problem was solved, what would you do differently?”)
miracle questions require family members to suspend present time frames and enter a different reality
‘exceptions’ are times when family members are temporarily free from their problem because the family goal is actually happening
‘scaling questions’ are used to identify concrete, behavioral levels and to assess for movement toward treatment goals (“On a scale of one to ten, how far do you think you have come in solving your problem?”)
scaling questions are also used to challenge family members to think about what is needed to get to the next level
emphasis is on ‘second-order (qualitative) change’ or a basic change in organization and structure
‘compliments’ are written messages praising families for their strengths and are always used as lead-ins to giving family tasks or assignments
‘clues’ are interventions that mirror the usual behavior of a family and are intended to alert a family that some behavior is likely to continue
‘skeleton keys’ are procedures that have worked before and that have a universal application that can help families unlock a variety of problems
five interventions with universal application

“Between now and the next time we meet, I want you to observe, so that you can tell me next time, what happens in your (life, marriage, family, or relationship) that you want to continue to happen.”
“Do something different.” This encourages families to explore a range of possibilities
“Pay attention to what you do when you overcome the temptation or urge to . . . perform the symptom or some behavior associated with the complaint.” This helps families understand that symptoms are under their control
“A lot of people in your situation would have . . .” This helps families realize there are more options than those they are currently exercising
“Write, read, and burn your thoughts.” This creates an opportunity to write about past times and then read and burn the writings the next day

Role of the therapist
determine how active a client family will be in the change process
visitor – not involved in the problem, not motivated to make changes, not part of the solution; best approach is to respect them, try and establish rapport, and hope they’ll become customers eventually
complainant – complain about situations, can describe problems even though they are not invested in solving them; best approach is to assign them activities where they can focus on exceptions, respect them, do not push them, hope they can become customers
customers – can not only describe a problem and their involvement in the problem, but are invested in solving it; best approach is to engage the person in solution oriented conversations and co-create assignments to reproduce behaviors that are exceptions to the problem
therapist helps clients access resources and strengths
therapist uses ‘pre-suppositional questions’ to lead families to believe that a solution will be achieved (e.g., What good thing happened since our last session?” and “How did you make that happen?”)
“several keys may fit the lock (or problem) well enough to open the door to change,” this illustrates the belief that “solutions do not need to be as complex as the presenting problem”
the treatment team is used to map or sketch out the course of successful intervention that will be a proper solution fit for the family and provide multiple perspectives about the problem
therapist assists the family in defining clear, specific goals and to create desired behaviors (i.e., solutions)
clients are encouraged to make small changes rapidly
clients are encouraged to focus on changes in behavior and perceptions and the mobilization of family strengths and resources
‘gender solution-focused genograms’ can help identify gender role messages that may be negatively influencing their present behaviors

Process and outcome
focus is on seeking solutions and accessing internal resources and strengths

the concept of pathology is not a part of treatment
client families are viewed as cooperative and wanting to change
families are frequently commended for a member’s behavior
change is inevitable
future oriented
finding exceptions to problem behaviors is important
asking of optimistic questions presupposes that change can happen
reinforcement of small but specific movement
treatment ends when “the agreed upon outcome has been reached”

Unique aspects of solution-focused family therapy

solution-focused therapies focus on and are directed by the family’s theory (i.e., their story)
therapists assist the family in defining their situations clearly, precisely, and with possibilities
the past is not emphasized, except when it calls attention to the present
the focus is on change rather than on achieving a clinical understanding
emphasis is on empowering families and unlocking their resources and strengths
emphasis on achievable goals, such as small changes in behavior
change is inevitable and clients want to change

Comparison with other theories

unlike Bowen or psychoanalytic theory, virtually no attention is paid to history
like strategic and systemic family therapy, solution-focused family therapy is brief regarding the situation focused on and the time of treatment
like behavioral family therapy, treatment ends when a behavioral goal has been reached
like systemic family therapy, a team is used to help the family help it self
like MRI strategic therapy, solution-focused therapy works to help client families change thoughts and actions to increase life satisfaction, although solution-focused therapists trust the family and use family resources more than MRI strategic therapists
solution-focused therapy is an effective adjunct to conventional medical treatment for migraine and holds promise for other headache symptoms

Key Terms

brief therapy a term used by deShazer for working with families which is sometimes called “brief family therapy.” It has to do more with the clarity about what needs to be changed rather than time. A central principle of brief therapy is that one evaluates which solutions have so far been attempted and then tries new and different solutions to the family’s problem, often the opposite of what has already been attempted.

certificates printed documents, often affixed with a logo that are given at the end of narrative therapy to bring closure to the process and affirm that a problem has been defeated.

clue an intervention in deShazer’s brief therapy approach that mirrors the usual behavior of a family. It is intended to alert a family to the idea that some of their present behavior will continue.

complainant a solution-focused term to describe a client who complains about and describes a situation or problem.

compliment a written message used in brief family therapy designed to praise a family for its strengths and build a “yes set” within it. A compliment consists of a positive statement with which all members of a family can agree.

consultants the term given to the deShazer team in brief family therapy. Consultants observe a family session behind a one-way mirror and transmit messages to the therapist at a designated break time in the session.

customers a solution-focused term for clients who are not only able to describe a problem and how they are involved in it but who are willing to work to solve it.

exceptions a term used in solution-focused family therapy for “negative” or “positive” space (or time when a family goal may be happening).

exceptions questions queries in narrative or solution-focused therapy directed toward finding instances when a situation reported to be a problem is not true. Most exceptiion questions begin with “what” and challenge the family’s view of the world as well as offer them hope that their lives can be different because some change has already taken place.

miracle question a brief therapy technique in which a therapist poses a question such as “If a miracle happened tonight and you woke up tomorrow and the problem was solved, how would you know?”

presuppositional question a question used in solution-focused therapy, such as “What good thing happened since our last session?”, that supposes a certain type of response.

scaling a solution-focused technique of asking questions using a scale of 1 (low) to 10 (high) to help clients assess situations.

second-order change a qualitatively different way of doing something; a basic change in function and/or structure.

skeleton keys in deShazer’s brief therapy approach, those interventions that have worked before and that have a universal application.

solutions desired behaviors in solution-focused therapy.

visitors a solution-focused term to describe clients who are not involved in a problem and are not part of a solution.

Classroom Discussion

1. Discuss the three types of questions used in Solution-focused therapy. Give an example of each. According to Solution-focused therapy, discuss how each facilitates client change/improvement.

2. Solution-focused family therapists do not consider causal factors important. How is it possible to work with families without a clear understanding of the underlying problem? How does shifting from a problem orientation to a solution focus facilitate change and improvement?

Multiple Choice Questions

Solution-focused family therapy is based on:
1. psychoanalysis
2. humanistic-existential psychology
3. social constructionism
4. humanistic-existential psychology
In Solution-focused therapy, ___________ factors are not important.
1. causal
2. social
3. cultural
4. all of the above
This question, used by Solution focused therapists, is intended to direct family members’ attention to times in the past or present when they did not have the problem.
1. exception question
2. miracle question
3. scaling question
4. none of the above
______________ are Solution-focused family therapy procedures that have worked before and that have a universal application that can help families solve a variety of problems.
1. clues
2. skeleton keys
3. pre-suppositional questions
4. compliments
In Solution-focused therapy, the best approach to use with ‘complainants’ is to:
1. respect them, try and establish rapport, and hope they will become customers eventually
2. assign them activities where they can focus on exceptions, respect them, and hope they will become customers eventually
3. engage them in solution oriented conversations and co-create assignments to reproduce behaviors that are exceptions to the problem
4. none of the above
Which philosophy states that knowledge is time and culture bound, as well as emphasizes that langauge influences the way people view the world?
1. Cartisian dualism
2. Aristotle’s golden mean
3. Modernism
4. Social constructionism
Which of the following is a basic rule of solution-focused therapy?
1. If it is not broken, do not fix it.
2. Once you know what works, do more of it.
3. If something does not work, do not do it again. Do something different.
4. All of the above are basic rules of solution-focused therapy.
Which of the following statements is accurate regarding deShazer’s thoughts on resistance?
1. It is important that counselors recognize family resistance and plan for ways of transcending it.
2. When it is encountered, therapists should consider delaying therapy, because it is a sign the family is precontemplative about change.
3. Families really want to change. Thus, when families do not follow therapists’ directions, they are “cooperating” by teaching therapists the best way to help them.
4. None of the above is accurate.
_______________ is considered a qualitatively different way of doing something.
1. First-order change
2. Second-order change
3. Third-order change
4. Systematic change
____________________ are not involved in the problem, are not motivated to make changes, and are not part of the solution.
1. Visitors
2. Complainants
3. Patients
4. Customers
____________________ are individuals who are not only able to describe a problem and how they are involved in it, but also are willing to work to solve it.
1. Visitors
2. Complainants
3. Patients
4. Customers
“What good thing happened since our last session,” is an example of what kind of question used by a solution-focused therapist?
1. Exception question
2. Miracle question
3. Presuppositional question
4. Praise
A therapist who inquires, “How did you make that happen,” is using what technique?
1. Positive blame
2. Presupposition
3. Praise
4. Negative positivity
In solution-focused therapy, when is therapy considered complete?
1. When the therapist determines that the family has reached a functional homeostasis
2. When the family determines that they have sufficiently ventilated their concerns.
3. When counselor and family acknowledge that an agreed upon outcome has been reached.
4. When the counselor determines that the family has gained insight into intergenerational stressors that have been affecting their current functioning.
What is the role of pathology in solution-focused family therapy?
1. Although it isn’t emphasized above strengths, solution-focused therapists like to know when they are working with pathology.
2. Pathology does not play a part in the treatment process of solution-focused family therapy.
3. Pathology is at the core of what solution-focused counselors use to conceptualize and treat families.
4. Only in families with serious mental health issues (e.g., schizophrenia) is pathology acknowledged and addressed in solution-focused family therapy.

Essay Questions

Describe the role of a solution-focused family therapist working with visitors, complainants, and customers.
Describe the unique aspects of solution-focused family therapy.

Chapter 16

Narrative Family Therapy

Chapter Overview

Narrative Family Therapy

Major theorists

Michael White
began working as a family therapist in Australia in the 1970s
influenced by the work of Gregory Bateson, Edward Bruner, Michael Foucault, and feminist theorists
narratives are ‘lived experiences’ that may be overshadowed by problem-saturated stories
comparison and evaluation is a source of life problems
people’s problems viewed as related to the stories they have about themselves
people’s problems are not systemic in nature
problem stories are related to oppressive cultural practices
one description of reality is no better than any other
White died in 2008, had set up Adelaide Narrative Therapy Centre

Premises of the theory
- non-systemic approach
- consistent with postmodernism and social constructionism
- there are no universal principles or truths
- based on narrative reasoning (i.e., stories, sub-stories, meaningfulness, and liveliness) rather than logico-scientific reasoning (i.e., empiricism and logic)
- emphasis is on empowering client families to develop unique and alternative stories about themselves that will lead to novel options and strategies for living
- ‘reauthoring’ is a way for families to highlight different stories than those that have been dominant
- externalization of problems is used where problems become separate entities that the whole family needs to solve as a team
Treatment techniques

externalization of the problem results in:
- decrease in unproductive conflict between persons
- decrease in the sense of failure an unresolved problem has on persons
- increase of cooperation among family members to problem solve and dialogue with each other
- opening up of possibilities for action
- freeing of persons to be more effective and less stress in approaching problems
influence of the problem on the person
used to increase the person’s awareness and objectivity (e.g., “How has the problem influenced you and your life and your relationships?”)
influence of the person on the problem
increases awareness of personal response(s) to a problem
helps people realize their strengths or potential in facing a situation
breaks a fixed perception or behavior pattern and creates possibilities for solving the problem in new ways
raising dilemmas
helping client families to examine possible aspects of a problem before the need arises
predicting setbacks
setbacks are almost inevitable
setbacks are best dealt with when they are planned for or anticipated
using questions
questions challenge families to examine the nature of the difficulties they bring to therapy and the resources they have available to handle their problems
‘exception questions’ identify instances when a situation reported to be a problem was not true; most begin with ‘when’ or ‘what’
‘significance questions’ are designed to reveal the meanings, significance, and importance of the exceptions
letters
writing letters to families after therapy sessions can extend the dialogue and remind families what happened in the session;
David Epston uses letters as case notes
celebrations and certificates
celebrations
used to bring closure to therapy
tangible affirmations of defeat of a problem
marks a new beginning
should be festive
certificates
should be tailored for the family and their situation
should be printed and affixed with a logo (e.g., apathy example in book)

Role of the therapist

collaborator and non-expert
utilizes basic relationship skills
does not view symptoms as serving any function
problems viewed as oppressive to families
questioner who works to find unique outcome or exceptions when families experience problems
examines the meaning of situations for families
therapist assists families to separate themselves from old, problem saturated stories
therapist helps families to construct new stories in which they, not their problems, are in control (i.e., reauthoring)
therapist searches for ‘unique outcomes’ or times when client families acted free of their problems, even if they were not aware of doing so

Process and outcome

three phases
deconstructing the dominant cultural narrative
client family challenged to examine exceptions
externalizing the problem
asked to change their behaviors and collectively address problem
reauthoring the story
reconstruct their story so that problems are less dominant and significant
narrative family therapy has been applied to couple relationships, substance abuse, adolescent sexual offenders, schizophrenia, post-traumatic stress disorder, AIDS, anorexia/bulimia, and grief

Unique aspects of narrative family therapy

emphasis on reauthoring of life stories
deconstruction of taken-for-granted realities and practices
externalize family problems to increase cooperation among members
search for exceptions rather than problems
plan for setbacks and the raising of dilemmas as a way of anticipating and planning for future problems
send letters to client families about their progress
celebrations and certificates issued when goals are achieved

Comparison with other theories

based on postmodern, social constructionist points of view
among the most intellectual and cerebral of any family therapy approaches
no normative patterns for families to strive for; each family determines their own life story and culture
strong emphasis on the use of language
little attention paid to family history, which is similar to solution-focused, strategic, systemic, and behavioral therapies
originated outside the United States
focus on collaborative therapeutic relationships, which is similar to solution-focused family therapy
not a systems oriented approach
centered on the importance of verbal behavior, the use and influence of language

Key Terms

deconstruction a narrative family therapy procedure that uses questions as a therapeutic tool to help clients more closely examine taken-for-granted realities and practices.

externalize problems a method of treatment in narrative therapy devised by White and Epston in which the problem becomes a separate entity outside of the family. Such a process helps families reduce their arguments about who owns the problem, form teams, and enter into dialogue about solving the problem.

letters a procedure in narrative family therapy where an epistle that is mailed to a client by a therapist serves as a medium for continuation of the dialogue between the therapist and family members and as a reminder of what has occurred in therapy session. In some cases, letters are case notes.

reauthoring a narrative family therapy approach for highlighting different stories in life than those that have been dominant. Such a process not only changes a family’s focus but opens up new possibilities as well.

significance questions queries in narrative and solution-focused therapy that are characterized as unique redescription questions. They search for and reveal the meanings, significance, and importance of the exceptions.

unique outcomes clients’ storied experiences that do not fit their problem-saturated story.

Classroom Discussion

1. What types of clients and client problems are best suited for Narrative models of treatment? Is this approach effective only with high functioning clients, or can it be used effectively to treat more serious problems (e.g., substance abuse, sexual abuse, or severe mental illness)?

Multiple Choice Questions

In narrative family therapy, ____________ is a way for families to highlight different stories than those that have been dominant.
1. deconstruction
2. externalization
3. reauthoring
4. celebration
“There are no universal principles or truths” is a theoretical premise most consistent with:
1. narrative family therapy
2. solution-focused family therapy
3. experiential family therapy
4. none of the above
A treatment technique in the narrative family therapy model is _____________, which is used to solve problems in that the problem becomes a separate entity that the whole family needs to solve as a team.
1. externalization
2. reauthoring
3. celebration
4. significance
The role of the therapist in narrative family therapy is:
1. expert
2. consultant
3. collaborator
4. director
Questions designed to reveal the meaning and importance of exceptions are called:
1. exception questions
2. unique outcomes
3. reauthoring questions
4. significance questions
Which individuals are considered the most prominent professionals associated with narrative family therapy?
1. John Winslade and Michael Durrant
2. Kathie Crocket and Jennifer Freeman
3. Michael White and David Epston
4. Stephen Madigan and Insoo Kim Berg
_____________________ is characterized by stories, substories, meaningfulness, and liveliness.
1. Narrative reasoning
2. Logico-scientific reasoning
3. Analytical reasoning
4. Bibliotherapeutic reasoning
________________ breaks the habitual reading and recalling of the complaint-saturated story as residing in the person, making the problem an external entity.
1. Problem-saturating
2. Externalization
3. Exceptionalizing
4. Paradoxing
According to narrative therapy, setbacks are best dealt with ________________.
1. when the possibility of them is ignored, focusing rather on hope and solutions
2. when they are planned for and anticipated
3. the old addage, “we’ll cross this bridge when we get to it.”
4. none of the above
_________________________ involves the redefining of lives and reliationships in a new narrative.
1. Differentiation
2. Individuation
3. Externalization
4. Reauthoring
______________________ are defined as clients’ storied experiences that do not fit the problem-saturated story.
1. Differentiations
2. Individuations
3. Reauthorings
4. Unique outcomes
In _________________________, individuals and families are challenged to examine exceptions to problems they bring in.
1. Reauthoring
2. Problem-unsaturating
3. Deconstruction
4. Reconstruction

Essay Questions

Describe the basic tenets of narrative therapy, and discuss why it is considered a post-modern, constructivist approach.
Discuss the role of the therapist in narrative therapy.
What are the unique contributions of narrative family therapy?

Chapter 17

Research and Assessment in Family Therapy

Chapter Overview

Family therapy has incorporated research based procedures since the early days of the field
In the initial development of family therapy, research came first and therapy was secondary
Many practitioners later abandoned research and assessment due to ethical, moral, and legal considerations as well as the complicated nature of family therapy research
There was a resurgence in research interest in the 1990s with increased incidence of published research articles and increased sophistication and quality of research procedures
Family assessment focuses on dimensions of particular families and is based on theoretical models of family function and dysfunction
formal or informal tests
behavioral observations
Family therapy research is even more refined in the 21^st century, with researchers like John Gottman studying real-life, real-time couple interactions and conveying research outcomes in practical ways to couples
Family assessment is less well developed and more complex compared to individual assessment

Importance of Research in Family Therapy

Knowledge – better understanding of phenomenon which leads to competence
Confirming and Verifying – concrete evidence that certain procedures work
Accountability – the ability to prove that family therapy is effective
Practicality – the influence of research findings on clinical practice
Uniqueness – research findings help establish both similarities and distinct differences with other mental health counseling approaches

Research Findings in Family Therapy

In general, most individuals and families improve with couple and family therapy, especially when compared with control groups
marriage and family interventions are more effective than no treatment with effects of treatment maintained at follow-up
improvement rates are similar to improvement rates in individual therapy
deterioration rates are similar to deterioration rates in individual therapy
family therapy is as effective as individual therapy for some personal problems, such as depression
family psychoeducation programs decrease relapse and rehospitalization rates among patients whose families receive such services
different kinds of marriage and family interventions tend to produce similar results
brief therapy (20 sessions or less) is as effective as open-ended or long-term therapies
participation of fathers in family therapy is much more likely to bring positive results than family therapy without him
co-therapists and co-therapy have not been shown to be more successful than sessions conducted by one therapist
persons receiving individual, marital, or family therapy reduce their health care use after therapy (the offset effect); largest reductions associated with conjoint therapy
therapists with good relationship skills are more successful than those with poor skills
marriage therapy outcomes are greater than family therapy outcomes; attributable to more difficult family therapy presenting problems
psychosomatic and substance abuse problems respond well to a modified version of structural family therapy
the type of family, its background, and its interactional style do not relate to family therapy success or failure
marriage and family treatments are moving more towards evidence based approaches
strong research by Jose Szapocznik and associates with Hispanic/Latino and African American families
development of brief strategic family therapy
development of Structural Ecosystems Therapy (SET)
development of Strategic Family Systems Rating (SFSR)
development of one-person family therapy (OPFT)

Two Types of Family Therapy Research

Qualitative research
- rooted in anthropology and sociology
- emphasis on open-ended questions
- use of extended interviews with small numbers of individuals/families
- results are often written up in an extended interview or autobiographical form
- often used in theory building
- visual and verbal data reporting rather than numerical data reporting
- participatory evaluation research
differs from other approaches in the degree of participants’ involvement
engages and empowers participants
more democratic than other types of research
Quantitative research
- rooted in scientific traditions of physics, chemistry, and biology
- most common form of research
- emphasis on closed-ended questions
- use of large sample sizes to gather information
- data are gathered in a precise form, frequently using standardized instruments, and reported in a statistical format
- results are used to “prove” or “disprove” theories and assertions
- findings often focus on interventions that made a difference in treatment
- quantitative research one reason family therapy is seen as a science

Difficulties in Family Therapy Research

Family relationships are complex (e.g., What within the family will be the focus of attention? The IP, marriage, whole system, cross-generational relationhips, etc.)
Environmental factors can impact research findings (e.g., home setting or laboratory setting?)
Time commitment, number of researchers needed, and expenses are great in family therapy research
Ethical and regulatory standards (e.g., National Research Act, Belmont Report) require close attention to rigorous ethical and procedural regulations
Research design
- ‘exploratory research’ – a qualitative approach used when issues are still being defined
- ‘descriptive research’ – the design is set up to describe specific variables
- ‘developmental research’ – focuses on studying changes over time
- ‘experimental research’ – classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated
- ‘correlational research’ – measures the degree of association or relatedness between two variables; usually conducted after the fact
Sampling
‘random sampling’ represents an entire group of families
‘random assignment sampling’ gives each family an equal chance of being selected; increases generalizability of results
‘probability samples’ are drawn from a known population such that it is possible to calculate the likelihood of each case being included
‘simple random sample’ – every family has an equal chance of being selected
‘systematic random sample’ – first family selected at random, then every nth family is automatically included
‘stratified sample’ – random samples are drawn from different strata or groups of a population
‘nonprobability sample’ is used when representiveness of a whole population is not as important and the information itself
‘convenience sample’ – using local families known by the researcher
‘snowballing’ – a sampling method in which participating families are asked to refer other families
‘purposiveness’ – involves choosing families because they are thought by the researcher to be representative of the whole population
Instrumentation
self-report instruments
easy to distribute to large numbers of families inexpensively
scoring is objective
easy to establish external validity
information helps family members understand other members’ concerns
easier to self-disclose through paper and pencil rather than usual ineffective ways
questionable construct validity
direct observational assessment
characterized by the use of coders, raters, or judges
weaknesses include interrater reliability and other biases
can be expensive and time consuming
videotaped observations with multiple observer ratings can be cost effective

Procedure

research procedures are not neutral but, instead, reflect the epistemology (e.g, world view) of the investigator
outcome research measures the impact of changes
process research examines the ‘how’ and ‘why’ of therapeutic effectiveness
time consuming and labor intensive
reveals which treatments are effective under which conditions and with what types of client situations
Theory
theory, research, and practice are interrelated in family therapy
research is generally based on questions rooted in theory and theoretical assumptions
Statistics
research results are usually reported statistically
statistics are used to report levels of change
descriptive statistics provide clinically relevant and readable statistics that are useful to family therapists
problem in reporting statistics related to whether sample was normally distributed or skewed
Validity/Reliability
the extent to which a measuring instrument measures what it was intended to measure
‘content validity’ - the degree to which an instrument actually taps into representative beliefs or behaviors that it is trying to measure
‘criterion validity’ – the degree to which what is measured actually relates to life experience, i.e., external criteria, especially behaviors
‘construct validity’ – the degree to which a measured performance matches a theoretical expectation, measures of similar construct
Reliability
the consistency or dependency of a measure
the degree to which the assessment measures differences between families
perfect reliability is expressed as a correlational coefficient of 1.0 (which is seldom achieved)

The Importance of Assessing Families

Assessment procedures are methods used to measure characteristics of people, programs, or objects
Assessment differs from testing
testing is usually a task in which people are asked to do their maximum best
assessment usually evaluates typical performances, behaviors, or qualities; it is broader than any test measure
assessment assist therapists to better understand a family’s structure, control, emotions/needs, culture, and development
The Diagnostic and Statistical Manual (DSM) is based on the medical model and is individually oriented
- little attention has been given in the DSM to marital and family diagnostic categories
- historically, relationships have not been diagnosed in the same way as mental disorders; the DSM has instead used other codes to describe relational/interpersonal problems or conditions
Besides DSM diagnoses, there is Tomm’s acronym approach to wellness and dysfunctional cycles in families, i.e., “HIPS” & “SLIPS”
Tomm’s model is a useful way of understanding how families change with time, events, and circumstances
Assessment information can help families better understand the dynamics within their relationships, clarify goals, and gain a sense of perspective
Assessment information documents services, the reasons behind services, and provides baseline and change data to increase accountability and professionalism

Dimensions of Assessing Families

Based on a systemic orientation
Utilizes the transactions between individuals rather than the characteristics of each given individual
Behavior is analyzed regarding its power to influence other family members and the variables of the ecosystem that have influenced it
Four elements of assessment (Fishman, 1988)
contemporary developmental pressures on the family
history
structure
process
Provides multiple perspectives of the family

Methods Used in Assessing Families

Informal assessment
observational data
assessment of a couple’s ability to create positive experiences in the relationship (Couples Creativity Assessment Tasks)
Family Assessment Form
Formal assessment
more than 1,000 assessment instruments available for family therapists
assessment areas include intimacy, power, parenthood, and adjustment
despite the wealth of assessment instruments available, family therapists are reluctant to use them because
using assessment instruments can remove family therapists from the cutting edge of innovative practice
some therapists lack adequate training in family assessment
family therapists who do assessment tend to use individually oriented assessment instruments, such as the MMPI-2 and the MBTI

Key Terms

assessment the administration of formal or informal tests or evaluation instrument(s) along with behavioral observations.

assessment procedure any method used to measure characteristics of people, programs, or objects.

construct validity the degree to which an instrument measures what it reports to measure.

content validity the degree to which an instrument actuals taps into representative beliefs or behaviors that it is trying to measure.

correlational research a design that calculates the degree of association or relatedness between two variables. This type of research is usually ex post facto (after the fact) rather than a priori (before the fact). With correlational research it is difficult to state in any precise way what factors were most influential and with whom.

criterion validity the degree to which what an instrument measures actually relates to life experience.

descriptive research a design set up to describe specific variables, for example, subpopulations.

developmental research a design that focuses on studying changes over time such as a longitudinal study.

direct observational assessment a measurement characterized by the use of coders, raters, or judges, who usually are not participants in the interpersonal system being studied and whose task is to unitize and assign meaning to some aspects of the process.

epistemology the study of knowledge.

experimental research a design that adheres to classic “hard science” methodologies, such as an hypothesis and dependent/independent variables. In an experimental research design, at least one variable is manipulated.

exploratory research a qualitative approach often taken to define issues, the design usually consist of interviews.

formal assessment the use of field-tested instruments.

informal assessment observational data related to either natural or game-playing situations that may or may not be quantified.

interrater reliability the degree to which raters agree on what they observe.

National Research Act (Public Law 94-348) the federal governments response to unethical research practices on human subjects prior to the mid-1970s. The National Research Act set up regulations governing human research including the establishment of institutional review boards (IRBs).

nonprobability samples a sample where that is nonrepresentative of a population, i.e., one where not everyone has had an equal chance of being selected.

offset effect the phenomenon where people reducing their use of health care following some type of therapy, i.e., individual, marital,family, or another behavioral health intervention. The idea is that following therapy, people are better able to cope with life events more effectively thus reducing their need or tendency to express emotional concerns physically.

participatory evaluation research a type of research in which clients are trained as individuals or focus groups to be involved as coresearchers in data analysis interpretation and write-up.

probability sample a sample drawn from a known population in such a way that it is possible to calculate the likelihood of each case being included in the sample.

qualitative research research that is characterized by an emphasis on open-ended questions and the use of extended interviews with small numbers of individuals/families. Results are written up in an autobiographical form. This research is often used in theory building.

quantitative research research that is characterized by an emphasis on closed-ended questions and the use of large sample sizes to gather information. Data are gathered in a precise form, frequently using standardized instruments, and reported in a statistical format. Analyzed and deductive conclusions are made that tend to “prove” or “disprove” theories and assertions.

random assignment sampling a procedure where everyone has an equal chance of being selected.

reliability the consistency or dependency of a measure.

sample a limited number of families representative of an entire group of families.

self-report instrument an instrument where a person reports what he or she thinks or feels about a matter, e.g., like or dislike doing a certain activity.

stratified sampling a method in which random samples are drawn from different strata or groups of a population.

systematic random sample a sampling design in which the first person to be studied is selected at random, and then every nth person is automatically included.

Tomm’s Acronym Family Systems Approach to Diagnosing Families a six stage system for diagnosing the pathology and health of families using acronyms such as PIPS (Pathologizing Interpersonal Patterns) and HIPS (Healing Interpersonal Patterns) to represent where families are in time and circumstances.

validity the extent to which an instrument measures what it was intended to.

Classroom Discussion

1. The family therapy field incorporated research based procedures early in its development and has enjoyed a resurgence in research since the 1990s. Where do you think the field should be headed in regard to research? What is needed to maintain a strong research focus?

2. Why are marriage and family practitioners reluctant to embrace research and assessment in clinical practice? What do you think could be done to retify this situation?

3. Theory, research, and practice are interrelated in family therapy in that research is generally based on questions rooted in theory and theoretical assumptions. Give an example of this interrelationship, using journal articles or other research studies to illustrate how these parts connect.

Multiple Choice Questions

Regarding the importance of research in family therapy, research findings help establish both similarities and distinct differences with other mental health practitioners. This is called
1. accountability
2. practicality
3. uniqueness
4. none of the above
In general, most individuals and families ___________ with couple and family therapy, especially when compared with control groups.
1. improve
2. worsen
3. stay about the same
4. relapse
_____________ approaches decrease relapse and rehospitalization rates among patients whose families receive such services.
1. couples therapy
2. marriage therapy
3. psychoeducation
4. brief
According to research findings, participation of _____ in family therapy is much more likely to bring positive results than family therapy without their participation.
1. fathers
2. mothers
3. co-therapists
4. extended family
Persons receiving individual, marital, or family therapy reduce their health care use after therapy, with the largest reductions associated with conjoint therapy. This is called
1. the offset effect
2. generalization
3. reliability
4. epistemology
Qualitative research emphasizes _____________, while quantitative research emphasizes ______________.
1. closed ended questions; open ended questions
2. open ended questions; closed ended questions
3. large sample sizes; precise data gathering
4. precise data gathering; large sample sizes
A ______________ is used when the representiveness of a whole population is not as important as the information itself.
1. systematic random sample
2. convenience sample
3. probability sample
4. nonprobability sample
_______________ is the extent to which a measuring instrument measures what it was intended to measure.
1. validity
2. reliability
3. interrater reliability
4. accountability
______________ is the consistency of an assessment instrument.
1. validity
2. reliability
3. interrater reliability
4. accountability
Which statement describes exploratory research?
1. focuses on studying changes over time
2. a qualitative approach used when issues are still being defined
3. classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated
4. measures the degree of association or relatedness between two variables; usually conducted after the fact
Which statement describes correlational research?
1. focuses on studying changes over time
2. a qualitative approach used when issues are still being defined
3. classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated
4. measures the degree of association or relatedness between two variables; usually conducted after the fact
Which statement describes experimental research?
1. focuses on studying changes over time
2. a qualitative approach used when issues are still being defined
3. classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated
4. measures the degree of association or relatedness between two variables; usually conducted after the fact
Which statement describes developmental research?
1. focuses on studying changes over time
2. a qualitative approach used when issues are still being defined
3. classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated
4. measures the degree of association or relatedness between two variables; usually conducted after the fact
Which statement describes descriptive research?
1. designed to describe specific variables
2. a qualitative approach used when issues are still being defined
3. classic research methodologies with hypotheses, dependent/independent variables with at least one variable manipulated
4. measures the degree of association or relatedness between two variables; usually conducted after the fact
_____________________ reseearch grew out of the scientific traditions of physics, chemistry, and biology and is characterized by an emphasis on data and closed questions.
1. Qualitative research
2. Quantitative research
3. Exploratory research
4. Mixed-methods research
A reseearcher is selecting a sample drawn from a different strata or groups of a populatoin. This type of sampling is called ___________________.
1. Simple random samplling
2. Systematic random sampling
3. Stratified sampling
4. Nonprobability sampling
John, a researcher, is asking families who have already participated in his study if they would refer other families to participate in the study. This type of sampling is called _____________.
1. Purposive sampling
2. Simple random sampling
3. Snowball sampling
4. None of the above
What is external validity?
1. How accurately an instrument measures what it purports to measure.
2. The consistency of a measurement over time.
3. The susceptibility of an instrument to extraneous variables
4. The generalizabiliity of an instrument
What is construct validity?
1. The degree to which an instrument measures what it purports to measure.
2. The consistency of an instrument over time
3. The interrater consistency of an instrument
4. The generalizability of an instrument
The means by which a group of people determine and gather knowledge is called ____________.
1. Outcome research
2. Epistemology
3. Evidence-based research
4. None of the above

Essay Questions

Describe and give examples for the following psychometric properties: construct validity, criterion validity, content validity, and reliability.
Discuss what quantitative and qualitative research are, and give an example of a family therapy-related research study using both quantitative and qualitative data.

Chapter 18

Working with Substance-Related Disorders, Domestic Violence, and Child Abuse

Chapter Overview

Substance-Related Disorders and Families

“Disorders related to the taking of a drug of abuse (including alcohol, to the side effects of medication, and to toxin exposure” American Psychiatric Association, 1994, p. 175)
Almost 60% of the world’s production of illegal drugs as well as a substantial percentage of legal alcohol products are consumed in the US
1 in 11 Americans suffers from severe addictive problems
One third of all American families are affected by alcohol problems
Illicit drug use is highest among Native Americans, lowest among Asian Americans
Two types of general alcohol use disorders
alcohol abuse – a problem pattern where the drinking interferes with work, school, or home life in addition to problems with the law and society
alcohol dependency – the person is unable to control the drinking even after trying

Substance abuse related disorders are considered to be family based
Families play a role in the development and maintenance of substance abuse
Pseudo-individuation may result in young people in families of addicts lacking basic coping skills and failing to achieve real identities

Manifestation of Substance-Related Disorders

Couple and family manifestations
unhealthy or dysfunctional methods of responding to substance abuse are usually tried first, such as
shielding the substance-related abuser from the negative consequences of his or her actions; minimizes the seriousness of the abuser’s actions
denial of the existence of the disorder; family fails to acknowledge the problem and may blame problem on external circumstances
negative feelings such as fear, anger, shame, or guilt result in relating to the world and each other in a despondent or anxious manner
unhealthy roles may be assumed that help the family to survive
enabler – a spouse or other family member on whom the abuser is most dependent and who allows the problem to continue and become worse
family hero – an adult or oldest child who functions to provide self-worth for the family
scapegoat – often a child who attempts to distract the family away from the abuser by acting out and being blamed for the family’s problems
lost child – usually a child who suffers from rejection and loneliness and offers a substance abuser family relief
family clown – often the youngest member who functions to provide the family with humor, thus reducing tension
deterioration of the couple or family itself by behaviors such as drinking or taking drugs together; not common but does occur
focus on the substance abuser occurs when the family spends the majority of their time focused on the substance abuser (e.g., begging, pleading, blaming, shaming)
misuse of family resources can occur when the rest of the family suffers due to a lack of money and effort to purchase family necessities

Individual manifestations

children may be confused about their self-identity and self-worth, resulting in controlling behavior in relationships to gain security
children in alcoholic environments are twice as likely to develop social and emotional problems (e.g., low academic achievement and law violations)
lower levels of attachment and bonding to others may make intimate relationships, such as marriage, more difficult
focus of energy and time on resolving issues related to the family of origin (e.g., numbness, confusion, guilt, denial, compulsive behavior)
inability to form long-lasting and intimate relationships

Engaging Substance-Related Disorder Families in Treatment

Family based treatments are among the most effective approaches for substance abuse treatment
Despite being a preferred method of treatment for families with substance abusing members, few family therapists report treating such families
Getting families to agree to come to treatment is a difficult challenge
Concerned significant others (CSO) can help engage families in treatment

old method was to surprise the substance abuser at a meeting known as “the intervention” in which CSOs would confront the abuser about the problems he or she had caused
modern approach is for CSOs to meet with therapists to learn behavioral skills designed to influence the substance abuser, with the goal to get the abuser into treatment
an effective approach with high success rates reported (64%)

Shift in focus to first forming a therapeutic system, diagnosing potential obstacles to engaging the family including involving the family system and issues involving the therapeutic system
Engaging the identified patient (IP)

usually an extremely powerful member of the family whose development has been arrested and who is resistant to therapy
therapist should make contact with the IP immediately and seek to ‘explore the IP’s goals’

Engaging disengaged family members

often the father or another family member who is “allegedly unwilling” to enter family therapy
direct contact can help convince such a family member that they have much to contribute to the therapeutic process

Engaging fearful or suspicious family members

reframe the therapeutic process to achieve family agreement on the specific nature of what will be worked on, thereby increasing their feeling of being more in control

Approaches for Treating Substance-Related Disorders

Families after engagement

many families have a high degree of resistance to therapy
relapse is common (up to 90% having at least one relapse in a four year follow up period)
using systems and supports in the community can reduce resistance and decrease relapse
community reinforcement approach (CRA) is highly effective and one of the top five treatments for substance abuse
physical, emotional, social, and vocational issues influence each other and must be addressed in therapy
‘environmental influences’ or the physical aspects of a family’s life are important to initially address (e.g., stopping the abusive behavior, getting the abuser ‘dry’)
‘multisystemic framework of family therapy’ is an approach based on social ecology or interconnected systems; recognizes that problem behaviors derive from many sources of influence and occur in the context of multiple systems
after the substance abusing behavior has stopped, work begins on interactional and activity changes both within and outside the family system
with adolescent IPs, it is important to clarify the drug consumption
experimenting – easier and more straightforward approaches work best
dependence and addiction require professional intervention
other issues that must be addressed
feelings
defense mechanisms
work by individuals within families
taking responsibility for behaviors

Structural-Strategic family therapy
- one of the first approaches to recognize substance abuse as a family systems problem
- begins with stopping the abusing behavior (e.g., detoxification, support groups)
- techniques include

family mapping
searching for family strengths
use of praise
respecting and working within cultural traditions

Bowen family therapy

works well for codependency
‘codependency’ describes a dynamic in a family involving an overresponsible family member (usually a spouse) and an underresponsible family member (the substance abuser)
Bowen approach works to increase differentiation and create a healthy balance of individuality and togetherness
family members learn to distinguish between subjective feelings and objective thoughts
family members increase flexibility, adaptability, and independence
techniques include
genograms
“I” position statements
reconnection of emotional cutoffs

Behavioral family therapy

works well, particularly for alcohol abuse
written behavioral contracts are effective in making specific behaviors explicit and measurable and providing alternative behaviors
written agreements tend to decrease the non-abuser’s anxiety and need to control the alcoholic and his or her drinking
Adlerian therapy
based on the premise that family members are discouraged
goal is to increase the social interest of family members
problem is shifted from a disease focused to a socially focused
group work can be helpful in raising self-esteem and increasing parenting and social skills
Systematic Training for Effective Parenting (STEP) helps parents understand family relations better and improve communication with children
Multifamily therapy
treating several families at one time
cost effective and high success rate
family members may experience their own dynamics in other families easier than in the context of their own family
women may benefit greatly from this approach and remain in therapy longer than other approaches
Use of community resources and prevention
often essential to supplement other treatment
family members gain information, insight, coping skills, and support
examples include Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Al-Anon
prevention approaches
keep persons or families from engaging in substance abusing behaviors
make other activities with positive outcomes available and central to their lives (e.g., art, athletics, meaningful work, community activities)
for teen alcohol abuse
give kids accurate information about alcohol use
present information through a ‘teen-respected’ source
help kids say yes to life, not just no to drugs
parent networking
set strict rules about drinking with kids
continue pressure to ‘take back communities’
primary prevention efforts require substantial community support and resources to be effective
secondary and tertiary prevention efforts work to prevent relapses, increase understanding of family dynamics, and provide support

Domestic Violence and Families

Domestic violence is defined as “aggression that takes place in intimate relationships, usually between adults” (Kemp, 1998, p. 225)
and “an attempt by one to control the thoughts, beliefs, or behaviors of an intimate partner or to punish the partner for resisting one’s control” (Peterman & Dixon, 2003, p. 41)
Approximately one-third of all married couples experience physical aggression
Referred to as
spousal abuse
partner abuse
marital violence
intimate partner violence
Includes physical, sexual, psychological, and economic abuse
Common forms are grabbing, slapping, pushing, and throwing things at one another
The worst form of domestic violence is ‘battering’ - severe physical assault or risk of serious injury
Gottman identified two types of male batterers

violent only within the relationship and so afraid of abandonment that he monitors his partner’s independence and is jealous of her every move, especially moves toward independence, such as getting a job
violent with just about everyone, exhibiting belligerent, provocative and angry behavior

well documented association between alcohol intoxication and battering (60% to 70% rate of alcohol abuse among men who batter)
Assessment of domestic violence
assessment is difficult due to legal barriers (e.g., court orders that mandate separation of family members) and psychological barriers (e.g., stigma surrounding domestic violence)
violent families tend to go to great lengths to keep the abuse a family secret
violent families often minimize the amount of violence and its impact on the family
assessing the power imbalance within the family helps individuals transition from violent to nonviolent behaviors and assists in learning the difference of each
‘open assessment’ shifts the focus from blame to how the violence has impacted the entire family and the dynamics associated with emotional expression, family finances, sexuality, and social connections

Approaches for Treating Domestic Violence

Two major positions about responsibility and domestic violence influence treatment options

both parties are equally responsible for the violence (conjoint or couples therapy)
the perpetrator is unilaterally responsible for the violence (intimate justice theory and education)

Conjoint or couples therapy
involves seeing the couple together
requires an assessment of safety issues
the man’s participation must be voluntary
special agreements must be established, that is, material on domestic violence will not be disclosed by the woman or the therapist until the woman is ready
an optimal therapeutic stance must be achieved, that is a context of self-protection that recognizes the emotionally disturbing, dehumanizing, and intimidating nature of domestic violence
conjoint or couples therapy may work if the following additional criteria are met
a history of only minor and infrequent psychological violence or abuse
no risk factors for lethality, such as prior use or threat of weapons
the man admits and takes responsibility for the abusive behavior and demonstrates an ongoing commitment to contain his explosive feelings without blaming others or acting them out
the couple talks about their wishes and the current relational dynamics
agreement is reached about new ways to behave and relate
Intimate justice
incorporates the ethical context of domestic violence in intimate relationships
encourages therapists to confront, challenge, explore, and educate clients about abuse of power in emotional systems
closely related to solution-focused approaches
emphasis on empowerment and disempowerment, internalized beliefs about how partners should be treated, and abuses of power in one’s family of origin
effective with couples who voluntarily enter therapy

Educational treatment

commonly based on intimate justice theory and cognitive behavior theory
Duluth model
a cognitive-behavioral model
people learn violent behaviors because they are reinforced in cultural and societal circles
people can unlearn these behaviors and learn new ones using cognitive-behavioral means, such as education
long term social and educational programs (i.e., at least a year) are more effective than short term
perpetrators must be held accountable for their actions

Child Abuse and Neglect in Families

Child abuse is maltreatment of a child due to acts of commission

physical, sexual, and psychological abuse

Child neglect is maltreatment of a child due to acts of omission

neglect and abandonment

Abusive families are usually chaotic and have relationship deficits
Effects of child abuse include

aggression
delinquency
suicide
distrust of others
poor school performance
later substance abuse
cognitive, academic, and psychological impairment

Childhood abuse can influence adult behavior (e.g., decreased life satisfaction, depression, low self-esteem)
Childhood sexual abuse (CSA) includes

unwanted touching (i.e., fondling)
making sexual remarks
voyeurism
intercourse
oral sex
pornography

CSA is significantly underreported, especially for boys
Most abuse of boys is done by perpetrators outside the family
Most abuse of girls is predominantly intrafamilial
Psychological abuse or emotional neglect is more constant in nature and more damaging throughout life

Approaches for Treating Child Abuse and Neglect

Treatment is complex and involves legal, developmental, and psychological issues
All states require mental health professionals to report child abuse and neglect
Before treatment can begin, legal issues must be resolved
Child abuse may not be treated until adulthood when other complications overlay the original problems
Therapists should not take the focus off the abuser, which may lead to a belief that the therapist is excusing the abusive acts
Focus on assisting the abuser to delay impulsive acts and the entire family to recognize and use alternatives other than violence
Motivation for change is highest right after an abusive act when the family is in crisis and the abuser usually feels badly about their behavior
Bowen family therapy can be effective in bridging historic issues from childhood and current adult behaviors associated with the history
Behavioral approaches can be effective in modifying behavior triggered by memories of the abuse
Group meetings attended by mothers and children in addition to family/network meetings alone can increase self-esteem and outcome

Key Terms

alcohol use disorder a term for alcohol problems that include two levels: alcohol abuse, a problem with drinking that interferes with work, school, and home life, and alcohol dependency, a disorder in which persons are unable to control their drinking of alcohol.

battering violence that includes severe physical assault or risk of serious injury.

child abuse maltreatment of a child through acts of commission.

child neglect maltreatment of a child through acts of ommission.

child physical abuse the bodily abuse of a child which may range from mild to severe.

childhood sexual abuse such acts as unwanted touching, i.e., fondling, intercourse, voyarism, making sexual remarks, oral sex, and pornography perpetrated by someone known or related to a child or by a stranger.

codependency a dynamic within a family where one member of the family underfunctions (such as a substance abuser) while another member of the family overfunctions (such as the codependent family member).

community reinforcement approach (CRA) use systems and resources in the community in which these people live to help them recover from substance abuse.

domestic violence aggression that takes place in intimate relationships usually between adults.

Duluth Model a cognitive-behavioral model of domestic violence treatment premised on the idea that people learn violent behaviors because of being reinforced for them in cultural and social circles. They can therefore unlearn these behaviors and learn new ones through cognitive-behavioral means, such as education.

enabler a spouse or other family member on whom a substance abuser is most dependent and who allows the abuser to continue and become worse.

environmental influences the physical aspects of a family’s life.

family clown a member of a substance abuse family whose function is to provide the family with humor and thus reduce tension.

family hero an adult or child who functions to provide self-worth for the family of a substance abuser.

identified patient (IP) a family member who carries the family’s symptoms and who is seen as the cause of the family’s problems.

intimate justice theory a theory of ethics that is used in the treatment of abuse and violence in intimate relationships. The theory confronts disempowerment abuses of power in a partnership while challenging internalized beliefs on how one should treat one’s partner.

lost child a child in a substance abuse family who suffers from rejection and loneliness.

multifamily therapy treating several families at the same time.

multisystemic therapy a research-backed theory and treatment, originated by Scott Henggeler, that views individuals, especially “difficult-to-reach children,” as nested within a complex of interconnected systems that encompass individual, family, and extrafamilial (peer, school, neighborhood) factors. Behavior is seen as the product of the reciprocal interplay between the individual and these systems and of the relations of the systems to each other. Developmental factors are included in assessment and cognitive-behavioral interventions are used.

pseudo-individuation/pseudo-self a pretend self. This concept involves an attempt by young people who lack an identity and basic coping skills to act as if they had both.

scapegoat a family member the family designates as the cause of its difficulties (i.e., the identified patient).

Systematic Training for Effective Parenting (STEP) an Adlerian based program that can help parents increase their understanding of family relations as well as improve their communications with their children.

Classroom Discussion

1. Couple and marriage therapy approaches appear to be well researched and highly effective. Given that, why is it that so few couples seek marital or couples therapy when there is abuse of any kind in the family? What do you think could be done to increase the numbers of such families?

2. In cases of substance abuse, unhealthy or dysfunctional methods of responding to the abuse are typically tried first. Given the enormous personal, family, financial, and societal impact of substance abuse, how would you explain the tendencies for family members to deny the existence of the abuse and to shield the abuser from the negative consequences of their actions?

3. In cases of domestic violence, there are two major positions about responsibility and domestic violence which influence treatment options:

both parties are equally responsible for the violence (conjoint or couples therapy)
the perpetrator is unilaterally responsible for the violence (intimate justice theory and education)

Take a position and defend the appropriateness of each approach, including the necessary conditions for selecting each one.

Multiple Choice Questions

When families protect the abuser from the consequences of his or her actions and minimize the seriousness of the substance abuser’s actions, this is called _____________.
1. denial
2. shielding
3. enabling
4. scapegoating
A spouse or other family member on whom the abuser is most dependent and who allows the problem to continue and become worse is called a(n):
1. enabler
2. family hero
3. scapegoat
4. lost child
The modern method of using concerned significant others in substance abuse treatment is to:
1. get them involved with support groups such as Al-Anon
2. teach them behavioral skills designed to influence the substance abuser
3. have them confront the abuser about the problems they have caused
4. have them surprise the abuser at a meeting known as “the intervention”
While many systemic therapy approaches work well in substance abuse situations, one approach is very cost-effective and has a high success rate. This approach is:
1. Structural-strategic
2. Bowen
3. Behavioral
4. Multisystemic
The worst form of domestic violence is
1. spousal abuse
2. partner abuse
3. marital violence
4. battering
There is a well-documented association between _____ and battering.
1. fear of abandonment
2. jealousy
3. alcohol intoxication
4. all of the above
One of the conditions necessary before selecting conjoint couples therapy is
1. an assessment of safety issues
2. an emphasis on empowerment
3. full disclosure of the violence
4. unilateral responsibility for the violence
An approach to treating domestic violence that is based on the ethical context of domestic violence in intimate relationships is called
1. Bowen family therapy
2. conjoint couples therapy
3. intimate justice
4. Adlerian therapy
Treatment of child abuse and neglect is complex and involves _____ issues.
1. historical, cultural, societal
2. environmental, community reinforcement, legal
3. legal, developmental, psychological
4. social ecology, behavioral, emotional cutoff
In child abuse cases, motivation for change is highest _____ an abusive act.
1. right after
2. right before
3. during treatment for
4. after treatment
________________________ is a condition in which a person is unable to control his or her drinking behavior even after trying.
1. Alcohol use
2. Alcohol abuse
3. Alcohol dependency
4. Alcohol intolerance
The _________________ is often the youngest member of a family, whose function is to provide the family with humor and thus reduce tension.
1. The lost child
2. The family jester
3. The family clown
4. The family enabler
With ______________________ there is a dynamic at play in the famly of overresponsibility and underresponsibility.
1. Fusion
2. Differentiation
3. Codependency
4. Family support groups
Mark’s heart rate decreases as he becomes more verbally aggressive, and he tends to get into verbal and physical altercations with most people in his life. Mark would be considered what type of batterer?
1. Pitbull
2. Cobra
3. Chamelion
4. None of the above
Which type of violence is considered low-level violence that is infrequent and noninjurious?
1. Verbal / psychological abuse
2. Intimate partner violence
3. Common couple violence
4. Domestic dispute
Which of the following is a cognitive-behavioral treatment for domestic violence, based on the premise that people learn violent behavior because they are reinforced for them in cultural and social circles?
1. Conjoint model
2. Ecological model
3. Duluth model
4. Ellis model
Child abuse is to ______________, as child neglect is to _________________.
1. commision; omission
2. omission; commission
3. duty to report; duty to support
4. duty to support; duty to report
Which of the following is the most common form of family violence?
1. Parent-child abuse
2. Step-parent – child abuse
3. Sibling abuse
4. Grandparent-child abuse
Which of the following is considered the least reported form of child sexual abuse?
1. Sexual abuse of girls by a family member
2. Sexual abuse of girls by a coach or teacher
3. Sexual abuse of boys
4. None of the above are underreported.
Which of the following is accurate regarding child abuse reporting?
1. 48 states (all contiguous) require mental health workers and other professional helpers to report child abuse nad neglect.
2. Failure to report child abuse can lead to disciplinary action by a regulation board but not conviction of a crime.
3. All 50 states require mental health workers and other professional helpers to report child abuse and neglect.
4. In all but 10 states, mental health workers can use their thereapeutic judgment about whether they should report child abuse.

Essay Questions

Describe the conditions that must be satisfied to ensure safety when using conjoint therapy with a couple in which psychological violence has been present, Concomitantly, discuss potential risks in providing couples therapy in these circumstances.
Describe four ways in which families maladaptively cope with a substance-related disorder.

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