Couple and Family Therapy

Chapter 10


COUPLE AND FAMILY THERAPY


Jay L. Lebow


Couple and family therapy would seem to be among the easiest forms of therapy to define and describe. Most simply, couple therapy involves the treatment of two partners who are in a relationship together, whereas family therapy describes the treatment of family members jointly.


Yet, couple and family therapies vary enormously in content and focus (Lebow, 2005a, 2005b). Both therapies are practiced in a variety of ways—some of which are extensions of the major traditions in individual therapies surveyed in this book (e.g., behavioral family therapy, Forgatch & Patterson, 1998, or psychodynamic family therapy, Boszormenyi-Nagy, Grunebaum, & Ulrich, 1991), and some of which are unique to family approaches (e.g., structural family therapy). Both couple and family therapy are primarily employed to improve family relationships, but they may be utilized to help improve a difficulty or respond to a challenge that an individual is facing. These complexities have generated innumerable forms of couple and family therapy.


DEFINING COUPLE AND FAMILY THERAPY


There are two essential ways family therapy has been defined: the first centered on the process goal of changing the family system as a focus of the change process, and the second by whom is present in sessions. Gurman, Kniskern, and Pinsof (1986) emphasize the former in their definition of family therapy:


Family therapy may be defined as any psychotherapeutic endeavor that explicitly focuses on altering the interactions between or among family members and seeks to improve the functioning of the family as a unit, or its subsystems, and/or the functioning of individual members of the family. (p. 565)


This definition best fits with the zeitgeist of family therapy, but leaves room for debate about whether a particular treatment is “family therapy.” From such a vantage point, any treatment that focuses on the system or aims to change the patterns between individuals is a family therapy. One corollary of this assertion is that family therapy can involve as few as one person. Therefore, there have been one-person family therapies, such as Bowen therapy, a treatment named after its developer, the psychiatrist Murray Bowen (1972). A second consequence is that just having more than one person in the room does not necessarily make for a family therapy.


In contrast, a simpler definition is sometimes employed based merely on who is in the treatment room. Such a definition offers less ambiguity about whether family therapy is being practiced (more than one related person in therapy is a necessary and sufficient condition for the presence of family therapy). However, such a definition diverges considerably from the core understandings of systems theory, which is about a view of interrelated functioning more than about counting heads, and fails to include some therapies such as the Bowen therapy that have been closely associated with the family systems model, while including other treatments (e.g., family meeting with a psychiatrist about prescribing psychoactive mediations) that are not typically thought of in the family systems tradition.


A second key issue in terms of delineating this group of therapies is that sometimes couple and family therapies are grouped together and sometimes separated. An argument can be made for each viewpoint. Because couple therapy focuses on adults in committed relationships, it includes a number of distinct features such as dealing with sexuality and the ever-present possibility that someone will choose to leave the relationship. Yet, couple relationships share many qualities with other close family relationships (e.g., the importance of communication, attachment, and problem solving), leaving the work of couple therapy somewhat like yet somewhat different from family therapy. Given the considerable overlap, this chapter covers both couple and family therapy, though presentations and writings about couple and family therapy tend to focus on one or the other (Gurman & Jacobson, 2003; Sexton, Weeks, & Robbins, 2003).


HISTORY OF COUPLE AND FAMILY THERAPY AND ITS VARIATIONS


Couple therapy had its origins in direct efforts to mediate marital relationship difficulties. Although there have been professionals who worked with couples since the beginnings of the twentieth century, for the first three-quarters of that century these couple interventions were held in relatively low regard and seldom referred to as psychotherapy (Gurman & Fraenkel, 2002). During much of that time, the dominating zeitgeist of psychoanalysis over the first half of the twentieth century, with its emphasis on the relationship between a single individual and therapist, relegated these methods and other conjoint therapies to the fringes. The major vehicle for working with relationship difficulties during this time lay in individual psychotherapies, where partners were thought to have the best prospect of resolving the issues lying behind their relational difficulties. To the extent that couples met in conjoint sessions, the primary goals remained the elucidation of individual issues. Some of the core techniques for working with more than one client in the room were developed by those who treated couples during this era (e.g., early variants of training in communication skills), but these conjoint therapies were largely considered adjunctive to what was viewed as the more important work of individual therapy.


The increased need for service that accompanied World War II spurred the emergence of a number of experimental and radically different modes of service delivery including family therapy. First developed in work with families who had members with severe mental illness such as schizophrenia, conjoint family therapy leapt to prominence in the 1950s and 1960s through the work of such figures as Nathan Ackerman (1968), Ivan Boszormenyi-Nagy (Boszormenyi-Nagy & Spark, 1973), Murray Bowen (1961), James Framo (1979), Jay Haley (1963), Donald Jackson (Jackson & Haley, 1963), Salvador Minuchin (1974), Virginia Satir (1967), Carl Whitaker (1973), and Lyman Wynne (1988). These pioneers shared a common belief in the core importance of the family system, as well as a great deal of personal charisma. They argued against the traditional individual-oriented view of problem development and treatment. The early work of this generation of family therapists spanned a wide range of family-focused interventions, crossing the boundaries of the schools of family therapy that subsequently emerged.


In the next stage of the field’s development between 1960 and 1980, several of these innovators including Ackerman (1970), Boszermenyi-Nagy (Boszormenyi-Nagy & Spark, 1973), Bowen (1972), Haley (1963), Satir (1988), and Whitaker (Whitaker & Bumberry, 1988) delineated specific theories of how family systems operate and strategies for intervention developed in relation to these theories; a first generation set of schools of treatment. What was once an iconoclastic view that families should have a central role in treatment whatever the difficulty transmuted into a new establishment with an array of diverse methods for treating families.


One common thread across these approaches was the incorporation of aspects of general systems theory and cybernetics (see next section) into their fabric (Bateson, 1972); most prominently, the theory that causality is best conceived of as a circular process in which the behavior of individuals is seen as interdependent and subject to mutual influence. The behavior of people who manifested problems, labeled as identified patients, was invariably seen as a reflection of underlying family processes. The family was viewed as the principal locus of problems, central in their development, and therefore also the most appropriate context for treatment. First-generation family therapists emphasized systemic concepts with a fervor that typically accompanies those who believe they have discovered a previously undiscovered truth, and they were highly critical of traditional methods of mental health intervention in which individuals were seen alone separated from the natural context of their social system (Whitaker & Keith, 1982). During this time, couple therapy came to be viewed as a subcategory in family therapy—a way of working with the couple subsystem in the style of family therapy. Individual therapy was seen as a non-systemic method of intervention, which at the very least was inefficient (Haley, 1975) if not errant in focus.


The influences that shaped the practice of this generation of pioneers themselves were enormously diverse. Some had backgrounds in psychoanalysis (e.g., Nathan Ackerman, James Framo), but others came from fields other than the mental health professions, such as anthropology (e.g., Gregory Bateson, John Weakland; Watzlawick, Weakland, & Fisch, 1974), engineering (Paul Watzlawick, 1978), and communication (e.g., Jay Haley). The dialectic of ideas from a multitude of disciplines made for thinking “outside the box” of traditional mental health treatment. New and exciting ideas were not only welcome but sought out. Jay Haley became quite interested in the work of the hypnotherapist psychiatrist Milton Erikson (Haley, 1985), bringing paradoxical interventions—in which therapists suggested the opposite of what was sought to produce psychological reactance and a reverse effect—into the mainstream of methods of practice in family therapy. In another example derived from very different sources in anthropology and communication science, the understandings about the importance of deviant patterns in communication in dysfunctional families, which had been identified in the work of Bateson and associates (Bateson, Jackson, Haley, & Weakland, 1956) and the parallel research of Wynne (Wynne & Singer, 1963) and Lidz (1959), also exerted an enormous impact, leading to an emphasis in several approaches on changing these deviant communication patterns.


In the 1970s and 1980s, the trend of moving from a shared vision of the core importance of the family system to an emphasis on the differences between the various systemic views continued to build. Distinct schools of family therapy, each with their own training sites and materials emerged. Some of these schools included a range of concepts from individual therapy, resulting in schools that were the family equivalents of methods of individual therapy, such as psychoanalytic (Ackerman, 1968; D. E. Scharff & Scharff, 1987), experiential (Whitaker, 1992), and behavioral (D. H. Baucom & Epstein, 1990). Still other schools rejected almost all aspects of individual models of treatment, exclusively focusing on aspects of the social system such as family structure (Minuchin, 1974), overcoming family homeostasis (Watzlawick, 1978), or intergenerational processes (Boszormenyi-Nagy & Spark, 1973; Bowen, 1972). Across this latter group of systemic schools, a vision developed of a powerful therapist (sometimes literally referred to as a wizard), jousting or performing some version of verbal judo to free up the family from its patterns. Through this time period, family therapy grew enormously in popularity and began to enter into the mainstream of practice.


In the most recent era in family therapy in the past 2 decades, voices emerged in family therapy that were highly critical of some aspects of the practices that had been dominant over the previous decades. Feminists highlighted the numerous male assumptions that were endemic to most models in family therapy (e.g., that fathers should hold the major executive position in the family) and called for a more egalitarian family therapy (Goldner, 1985, Hare-Mustin, 1992). Still others focused on the insufficient attention to culture in family models, emphasizing specific adaptations to practice in the presence of various cultural contexts (Boyd-Franklin, 2003; McGoldrick, 1998, 2001; McGoldrick, Preto, Hines, & Lee, 1991).


Yet another set of criticisms surrounded the emphasis on homeostasis, the tendency of systems to return to a previous balanced state, in which families were viewed as resistant to change. Alternative visions developed based on notions of family resilience (Walsh, 2003), and flowing from these visions of families, widespread questions were raised about the role of the therapist as the powerful enactor of change depicted in most of the early family therapy models. Those associated with social constructivism argued that knowing and knowledge are socially constructed through language and discourse, and models of family therapy developed that emphasized collaboration (Anderson, 2003) and the personal construction of narrative (White & Epston, 1989).


Research also has emerged over the past decade as a crucial input into treatments, including both research on family therapy and basic research on families. Some of this research has led to major revisions in point of view. The now antiquated notion of the double bind theory suggesting that families produced schizophrenia by creating binds for identified patients, in which two contradictory ways of being were simultaneously called for (Bateson et al., 1956), has fallen from view primarily because it was unsupported by data about life in these families (Goldstein et al., 1989). Instead, newer concepts such as the powerful role of what is termed expressed emotion in these families (a combination of emotional arousal and criticism) have emerged from research as empirically supported mechanisms that increase risks of recidivism, symptoms, and dysfunction in these families (Miklowitz & Hooley, 1998).


Ultimately, even the exclusive focus of family therapy on life in the family has been challenged. The center of family therapy has moved away from the simplistic notion that the family is the sole etiologic agent in the development of difficulties, and the concept that family therapy is the preferred method of intervention for most difficulties. Instead, an integrative viewpoint has emerged that includes not only the concepts from various family methods of intervention, but also interventions at the level of the individual (Lebow, 1997, 2003) and larger system (Breunlin, Schwartz, & Kune-Karrer, 1997; Schoenwald, Borduin, & Henggeler, 1998). Some have even called for a basic redefinition of systemic therapy, moving from a specific focus on the family to a broader vision of consultation with social systems, including but not limited to families (Wynne, McDaniel, & Weber, 1988).


In the past 20 years, couple therapy has also begun to have a distinct identity, often separated in discussion from family therapy and with its own unique methods of intervention. Although there remain many parallels with family therapy, couple therapy has developed its own literature (Gurman & Jacobson, 2003), its own set of treatment models (Gurman & Jacobson, 2003), and a separate body of research examining couple relationships (Bradbury, Fincham, & Beach, 2000; Gottman & Notarius, 2000).


Couple and family therapy has been a field percolating with ideas and concepts and ways of examining the family and how to impact it. It has been a continuously developing field in which treatments have emerged and been refined, theory has undergone considerable revision, and assumptions have been continually examined in the emerging vantage points about family in the broader society. As we enter the twenty-first century, family therapy is emerging as a mature field of endeavor with a scientifically based well-defined set of treatments aimed at relational processes and at individual difficulties as they are manifested in families (Sexton et al., 2003).


SYSTEMS THEORY APPLIED TO PERSONALITY AND PSYCHOPATHOLOGY


Family systems theories have a radically different focus than other theories of human functioning and psychotherapeutic change processes insofar as these theories focus on collective family process rather than individual functioning. From a family systems vantage point, people act as they do because they are parts of a system, not because of individual development, intrapsychic conflict, or learned behavior.


Perhaps the most crucial theory in family systems approaches does not even derive from human psychology but from biological and physical systems: general systems theory developed by von Bertalanffy (1976). General systems theory was developed as a way of understanding all systems, animate and inanimate. The central tenet of general systems theory is that the whole is more than the sum of its parts, and therefore to understand any part (e.g., an individual), we must grasp its relation to the whole of which it is a part (e.g., the family). Humans are viewed as part of what is termed an open system in which there is ongoing exchange with those lying outside the system, be they other individuals, families, or other systems. Open systems remain subject to influences from outside the system. Systems (e.g., families) are made up of subsystems (e.g., a couple, children) that affect one another and add to one another in ways that make the system more than the sum of its parts.


General systems theory also focuses attention on how systems evolve, be they particles in space or human families. The principle of equifinality suggests that there are many paths to reach particular configurations in the system and moreover that the particular pathway by which a configuration has been reached does not matter. Applying the principle of equifinality to family systems, focus shifts to the state the family is presently in and away from how the family reached that state. Thus, general systems theory presents an ahistorical point of view. History and individual motivation have little importance, whereas the topography of how the system is presently organized assumes paramount importance.


In the context of general systems theory, how behavior is understood is viewed as a function of the context in which it is conceived. In a classic example cited by Watzlawick, Beavin, and Jackson (1967), what it means to see a man quacking at ducks is significantly altered by the knowledge that this man is Konrad Lorenz, a scientist engaged in experiments about imprinting. Without that piece of information, the same behavior looks eccentric or psychotic; with it, scientific. This application of systems theory suggests that sense can be made of this and most behavior in the appropriate context. In the early history of family therapy, such a focus on context became the cornerstone of the viewpoint that the behavior of all family members makes sense if only the meaning of the behavior in the appropriate context could be deciphered. Following from this notion, even severe mental illness was seen as the product of behavior that made sense in a particular context (e.g., in a very pathological process), although such behaviors appeared to make little sense when seen outside of that context.


An extension of this same concept emphasized early in the history of family therapy was labeling family members displaying psychopathology or other problematic behavior as identified patients. These identified patients were only the members of the family who had been identified as having the problem that actually was a problem in the whole system. They were typically seen as carrying the burden of the problem for the system; the real patient was the family. Therefore, family therapy involving the entire family system was seen as the most appropriate method of bringing about change. A corollary of this vantage point was the dismissal of the biological basis for even severe mental illness (Haley, 1963).


Another emphasis of general systems theory is on what are termed circular paths of causality. Rather than focusing on linear pathways in which one action causes another, circular causality focuses attention on recursive patterns of mutual interaction and influence. Even if the behavior one person affects that of another (e.g., a father punishes his child), the response of the second person must be understood to also affect the behavior of the first, leading to a circular process (e.g., the child’s aggressive behavior leads to the parent’s punishment; the parent’s punishment leads to the child’s temporarily stopping the behavior, followed by further aggressive behavior). From this perspective, the family system, not a single person, is responsible for the behavior that is maintained through such circular pathways.


Cybernetics, the science of communication and control in man and machine developed by Norbert Weiner (1967) and others, offered a complementary additional view of systems that also was crucial in the early development of family therapy. Cybernetics emphasized a view of the system as self-correcting, influenced in an ongoing way by feedback—the process by which a system gains information to self-correct to maintain a steady state or move toward a goal. Within cybernetics, positive feedback describes input that increases deviations from the steady state, whereas negative feedback describes input that reduces such deviations. Homeostasis is seen as a powerful force moving the system toward a steady state. Early family therapy was profoundly influenced by the idea that human systems were homeostatic, moving toward the reduction of change. As a result, most first-generation family therapies were based on the notion that powerful interventions needed to be created to reorganize the family and overcome homeostatic forces.


A third cornerstone of early systemic theory centered has been on communication processes. The early double bind theory of schizophrenia (Bateson et al., 1956), served as a launching point in the family therapy field for an emphasis on communication processes, suggesting that even psychotic process was the product of disturbed communication. A double bind begins with two or more parties involved in an important, ongoing relationship. A primary injunction is given, such as “show me your feelings.” A second injunction then follows that conflicts with the first, such as “The negative feelings you have are unacceptable and should not be stated.” Given that the recipient of the communication cannot leave the field, the double bind theory suggested that repeated exposure to such binds would result in responses that resolve the bind through engaging in psychotic process. Although this theory has long ago been rejected as an explanation for schizophrenia, it served as the launching point for vigorous examination of communication processes in families. Beginning with the premise that you can’t not communicate (Watzlawick, Beavin, & Jackson, 1967, 1969), family therapists developed a strong interest in language and nonverbal forms of communication.


Although general systems theory, cybernetics, and communication theory continue to have an important role in guiding the understanding of family therapists, recent critiques and reappraisals have tempered many of the most radical conclusions arrived at when these principles were first applied to family systems. One line of criticism has centered on the notion of identified patients. Much recent research has shown very real disabilities in those with mental illness. Most in the family therapy field no longer use this term. Furthermore, the psychoeducational movement in family therapy has called attention to the costs from such an approach of alienating families who felt blamed for the disorders with which they were struggling and therefore became reluctant to seek the treatment they needed.


Others have emphasized the limits of circular notions of causality (Dell, 1986; Goldner, 1985), pointing to the dangers inherent in the idea that all parties are equally responsible for sequences of behavior. Specifically, family violence has been cited as an example where individual responsibility and lineal arcs of causality need to be highlighted, to prevent the inappropriate conclusion that batterers and victims have coequal responsibility for violent behavior (McGoldrick, Anderson, & Walsh, 1989). At present, there is broad agreement among family therapists that both lineal and circular pathways of causality and problem maintenance need to be considered in assessing family systems.


More recent systemic thinking has had less of an emphasis on homeostasis and added a greater emphasis to morphogenesis, the systemic force moving the system toward change. Emphasizing morphogenesis creates very different implications for psychotherapy than emphasizing homeostasis. A belief in the power of morphogenesis suggests that initiating the process of change is likely to kick off a positive chain reaction potentiating change, very unlike the minimization of change thought to be active in a perspective emphasizing homeostasis.


Empirical research never was able to demonstrate high frequencies of double binds on the part of parents of schizophrenics (or even reliably rate what was in fact a double bind) and the double bind theory is no longer discussed as an explanation for severe mental illness. Nonetheless, the emphasis on understanding communication among family therapists has continued. Communication processes remain central in family therapy but with a more tempered evidence-based view of those processes.


Additionally, recent models of family therapy have moved a considerable distance from the ahistorical black box (with nothing inside) of early systems theory. Family therapies now readily integrate knowledge about individuals and individual development with systems notions.


Yet, even with all this movement away from the invocation of physical systems as sufficient explanations of what occurs in human systems, the core idea of the system in which each part affects each other parts remains at the center of today’s family therapy. This simple (but easy to ignore, given the power of individual psychology) insight, now empirically demonstrated in innumerable research studies, remains one of the great insights in the history of the understanding of human psychology and mental health treatment.


THEORIES OF PSYCHOTHERAPY


Although systems theory is central in most family therapy, the major approaches to family therapy have almost all incorporated other concepts as well, providing a rich array of models that emphasize different aspects of family life and distinctive strategies for intervention. Some of these models have been directed to specific difficulties (e.g., Kaplan’s treatment for sexual disorders; Helen Singer Kaplan, 1995), but most have been focused on the treatment of a broad range of problems. Some family therapies aim to resolve difficulties that are explicitly about family relationships (e.g., couple therapy aimed at marital dissatisfaction; family therapy aimed at overcoming differences between parents and their grown children), whereas other family therapies utilize a family systems approach to intervene with problems that manifest in the behavior of an individual, such as depression. The numerous couple and family therapies can be divided into a few distinct categories based on emphasis on structural, strategic, cognitive-behavioral, psycho-educational, intergenerational, psychodynamic, experiential, narrative, and integrative schools of family therapy.


Structural Family Therapy


Structural family therapy, developed by Salvador Minuchin (1974; Minuchin, Lee, & Simon, 1996; Minuchin & Nichols, 1998), is almost exclusively derived from systems theory. Structural family therapy highlights the power of the family system, emphasizing the impact of the structure of the family. Individual health or dysfunction is viewed as the product of health or dysfunction in the family structure. Minuchin views structure as the regulating codes as manifested in the operational patterns through which people relate to one another in order to carry out functions. Minuchin focused on three primary dimensions of structure: (1) boundary, (2) alliance, and (3) power.


Boundaries are the rules defining who participates and how they participate in various operations (i.e., who is in and who is out of an operation), thus regulating the amount and kind of contact between family members. The strength of such boundaries varies considerably, ranging from rigid boundaries that result in “disengagement” to very permeable resulting in what Minuchin termed enmeshment, a sense of having no boundaries from one another. At the disengaged end of the spectrum, families act like they have little to do with each other, leaving the individuals substantially disconnected. At the enmeshed end, family members intrude into functions that are the domain of other family members. Structural family therapy aims to move families away from the extremes of enmeshment and disengagement toward boundaries that are flexible and fit with the family’s life and situation (e.g., parents maintaining some boundary around their sexuality while including children in discussions of important family decisions).


Alliances, the second component of family structure, represent the joining or opposition of one member of a system to another in carrying out various operations. From a structural perspective, alignments are seen as inevitable, but become dysfunctional when they become fixed and unchanging (stable coalitions) or when they are primarily cross generation. Triangulation describes the process when each of two people demand that a third join with them against the other. Structural family therapy aims to create alliances that are functional (e.g., parents supporting one another) while at the same time allowing some flexibility in alliance in the context of the range of situations a family encounters.


Power, the third component of family structure, depicts the relative influence of each family member on the outcome of various family activities. From a structural perspective, power can be functionally distributed with primary locus in the older generation but can also easily become rigidly held by one individual or coalition, or there can be overly weak executive function. Power is seen as best primarily held in the hands of an executive parental coalition, but in such a fashion as to leave everyone with some degree of power.


Given that function and dysfunction in families and individuals are viewed as flowing from family structure, treatment in structural family therapy principally focuses on efforts to change these elements of family structure. Additionally, because family systems are viewed in the structural model as moving to limit change processes (i.e., as homeostatic), structural therapists seek to create and build on powerful in-session experiences to work to alter the family’s organization at moments of crisis. One common technique is to promote in-session family members’ habitual patterns of relating at a moment of crisis (called enactments) and build alternative methods of structurally relating at these moments. For example, the family in which there is a primary father-child coalition may be brought into circumstances where such a coalition crisply emerges, invoking a crisis that provides a learning experience for trying out a parental coalition.


Throughout treatment, structural family therapy emphasizes the joining with the family in utilizing such specific techniques as tracking (adopting the symbols of the family’s life), accommodation (relating to the family in congruence with the family’s patterns), and mimesis (joining with the family by becoming like the family in manner or content). Ultimately, strategies of change are directed to restructuring the system. Symptomatic change in identified patients remains a goal, but this is viewed as largely a by-product of the more important change in the structure of the system, which is seen as crucial in the maintenance of individual change.


The structural approach today remains the most influential specific school within family therapy. Some of its ideas, such as the importance of boundary, alliance, and power in family systems have come to be broadly accepted as part of widely accepted theory in family therapy. Furthermore, several of the most effective evidence-based methods in family therapy such as brief strategic family therapy (Szapocznik & Williams, 2000), multidimensional family therapy (Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004), and multisystemic therapy (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) all incorporate structural interventions.


However, there also has been considerable criticism of some aspects of structural theory, especially as it was initially developed. Most prominently, the stereotypic gender-based assumptions about the roles of men and women in structural family therapy have resulted in considerable criticism, particularly from feminists. Other criticisms have questioned the emphasis derived from the principle of equifinality resulting in a very limited concern with family history or the internal process of individuals. Recently, the field including Minuchin himself (Minuchin & Bertrando, 2002; Minuchin et al., 1996) has moved to a more gender-aware version of the structural approach, that also acknowledges a greater appreciation for the importance of history.


Strategic Approaches


Strategic approaches are the most purely systemic among family therapies, aiming for the most expedient, focused intervention that can change the system. Strategic therapists envision change as a discontinuous process of making a leap to some different mode of systemic functioning. Building on this view, the goal of strategic therapy is to intervene, spur a new better mode of functioning, and then promptly end the treatment (Watzlawick et al., 1974).


Strategic models give a prominent role to paradoxical interventions in which directives are offered that if acted on would move the family in the opposite direction from that which is desired. Although direct interventions are also part of the strategic therapist’s repertoire, the rapier-like effort to find the simplest and most expedient pathway to change is best represented by the use of paradoxical directives. Strategic methods have also been closely associated with the use of team approaches in which observers either in the therapy room or, more likely, behind a one-way mirror actively participate in treatment, typically offering commentary or directives to the therapist and family. Such directives from the relatively anonymous group of observers normally have a considerable impact. For example, the group behind the mirror might implore a family to not change too quickly, calling attention to the discomfort of dealing with the transition the family would have to address if the family’s youngest child left home, a transition that can be avoided as long as that young adult continues to have problems that block independence.


Strategic methods also have been associated with a cool detached stance on the part of the therapist (as in the Mental Research Institute [MRI] model described below), although there have been significant exceptions to this trend. Strategic therapies center on changing cycles of feedback in the family, but do not seek to enable insight in the family about such cycles. Change, not learning about the change process, is clearly the focus in strategic models.


Mental Research Institute Model


The first strategic model in family therapy was the MRI or Palo Alto model developed by Jackson, Watzlawick, and Weakland, and their colleagues (Watzlawick et al., 1974). The MRI model derived from a mix of general systems theory, cybernetics, and the study of communication processes. The MRI model views problems as a natural part of family life that families typically encounter and deal with without help. Families’ need for professional help with their problems is not seen as stemming from the problems that are encountered themselves, but instead from how the members of the family try to deal with these problems. When families become stuck in efforts to solve problems (termed doing more of the same), repeating unsuccessful solutions, change is viewed as unlikely. Therapy instead focuses on the creation of what is termed second order change, an alteration in the rules of the system that govern interactions as opposed to the effort at first order change to change behavior. Treatment begins with identifying the ways problems are maintained by the behavior in the system, followed by examining the rules that lie beneath these behaviors, and finally by efforts at changing these rules. The paradoxical interventions already discussed and reframing are viewed as the most powerful tools for instigating second order change. Reframing consists of active efforts by the therapist to create a new and different understanding of events that has a more benign meaning and therefore more readily accepted. For example, by recasting behavior that has been seen as bad and out of the individual’s control (e.g. acting out) as having a benign meaning (e.g. seeking independence), a different reality is invoked that can lead to change.


Paradoxical directives capitalize on the forces in social systems that move against efforts from outside the system to spur change. In carrying out such a directive, the therapist might list, for example, reasons why change is not likely to be productive or even harmful. Treatment within the MRI model always remains brief and focused. The therapist’s detached stance is not designed to make for long-term attachment, and the model suggests that termination be encouraged as soon as problem resolution has been substantially initiated.


The MRI model is no longer frequently practiced but remains highly influential in the broad practice of family therapy. Several of its core concepts (reframing, more of the same, first and second order change) have been widely adopted. Reframing has become one of the most frequently utilized techniques in couple and family therapy, employed by therapists of many specific regardless orientations (Alexander & Sexton, 2002). However, the paradoxical bent of the intervention strategy and the detached stance of the therapist have led most of those who have tried this approach to move on to other models that emphasize a more collaborative approach between clients and therapist. There has been little empirical support available for this approach.


Haley’s Problem-Solving Therapy


Jay Haley’s (1987) problem-solving therapy and the closely related work of his colleague Cloe Madanes (Madanes & Haley, 1977) combines a strategic use of paradoxical techniques with goals that typify structural family therapy. Problem-solving therapy strongly emphasizes therapists understanding and working with the function that behaviors serve in the system. Most often, this function is conceptualized as a struggle for power and control.


Specific focus of assessment centers on triangles (who supports whom in interaction) and hierarchy (who has what power), but these formulations are not directly shared with the clients. Instead, the family is offered directives that flow from a consideration of solutions that have been attempted looking to stimulate the family to engage in new and different behaviors. Many of the techniques utilized by Haley and Madanes derive from the hypnotherapy of Milton Erickson (Haley, 1973), specifically aimed at increasing suggestibility and openness to change. For example, in the pretend technique the family is directed to have children pretend to have symptoms and parents to pretend to help them. This is a paradoxical technique suggesting the possibility of overt control over patterns thought to be out of conscious control. Other commonly employed techniques aim at establishing a coalition between parents to help adult children leave home (Haley, 1997).


Haley remains a highly controversial figure in the family therapy field in his long-held adherence to some of the earliest systemic conceptualizations of family therapists; for example, the view that identified patients carry symptoms entirely due to the function these symptoms serve in the family and a denial of the existence of mental illness. For Haley, psychopathology is always the product of a dysfunctional social system, not due to biology or individual psychology. These ideas, once brilliantly presented as a welcome contrast to the determinism of biological and psychoanalytic formulations (Haley, 1963, 1969), now appear rigid and overblown in the wake of the development of the considerable literature delineating the biological and psychological basis for severe disorder, and the emergence of highly effective psychoeducational treatments that demonstrate how an approach can be family based and yet consistent with the best data about schizophrenia and other mental illness.


Milan Systemic Therapy


A number of strategic therapeutic approaches have been developed in Milan, Italy, by Selvini-Palazzoli, Boscolo, Cecchin, Prata, and their colleagues in various combinations (Boscolo, Cecchin, Hoffman, & Penn, 1987; Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1977). Versions of these models have varied enormously although all have maintained a strategic focus.


In the classic Milan therapy that brought worldwide recognition to this group, sessions are conducted only once per month and almost always involve a team of therapists seated behind a one-way mirror in addition to a therapist in the room. The team forms a hypothesis about the family that is modified and refined over the course of treatment. During a break during each session, the team formulates a strategic message to be delivered to the family that the therapist then presents to the family. Most of these interventions include some version of what the Milan group terms positive connotation and/or the prescribing a therapeutic ritual. Positive connotation consists of reframing behavior in a positive light, most frequently through suggesting how the behavior serves the goals of the system. Positive connotation is a form of reframing designed to change the family view of dysfunctional behavior to a more positive view while also decreasing resistance by allowing each family member to emerge with a positive view of his or her behavior. The rituals prescribed are designed to exaggerate or challenge rigid patterns in the family. Most of these prescribed rituals have an ironic quality and engender confusion, although some (e.g., one called “odd and even days,” in which control is given to each parent on alternating days) merely serve to call attention to patterns in the family, and thereby help the family to see their ability to impact the situation and resolve their difficulties. The Milan approach also strongly stressed the value of therapist neutrality in delivering these interventions.


In the most influential variant of the Milan methods, Boscolo and Cecchin (Boscolo et al., 1987; Cecchin, 1987) abandoned directives and instead focused on what they termed circular questions. These questions are used to learn about differences in the family that might provide clues to recursive family patterns. Circular questions include ones about differences in the perception of relationships (who is closer?), differences between before and after something else happened (Were you more depressed before or after the birth of the baby?), and hypothetical differences (If you had not married, how would your life be different?). Curiosity is the essential ingredient in circular questioning. The aim of circular questioning is not to move the family toward a specific goal, but to initiate conversation that can lead to a better understanding of how the present situation and the family’s behavior in it came about, what the systemic patterns are that help keep the family from resolving their difficulties, and what are the most productive pathways toward change. Work in this model is much more collaborative than in the earlier version of Milan therapy.


Selvini-Palazzoli (Selvini-Palazzoli & Viaro, 1989) added yet another variant of the Milan model. Selvini-Palazzoli came to believe that disturbed patients were inevitably caught up in what she termed the dirty game, a power struggle between parents in which patients’ symptoms help support one parent. Her response was what she called the invariant prescription, applied to all families. In the invariant prescription, the therapist suggests to parents that they tell family members that they have a secret and go out together mysteriously without warning other family members, and that they then observe the family’s reaction. The invariant prescription aims to help strengthen the alliance between the parents and enable understanding of dysfunctional patterns in the family. This approach acquired little support because of its highly pathological view of family process, its ignoring the mounting evidence demonstrating the importance of expressed emotion in recidivism in severe mental illness, and its failure to respond to differences among families.


All tolled, the Milan approaches have proven to be highly influential. Although only a small number of family therapists practice any of the variants of Milan therapy, the attitude of curiosity and prompting of circular questions have come to serve as the base of investigation for many family therapists. There has been very little empirical testing of the Milan approaches.


Solution-Focused Therapy


Solution-focused approaches accentuate solutions rather than problems (see also the discussion of these models in Chapter 6). Among the best known of this solution-focused set of approaches is the work of Steve de Shazer (1988) and Insoo Kim Berg (Berg & Miller, 1992), Bill O’Hanlon (1993), and Michele Weiner-Davis (1987). Solution-focused approaches begin with the assumption that clients want to change and reject the notion of deeply ingrained pathology. Instead, these approaches seek to introduce ways of thinking about and facing difficulties that can initiate the family’s own process of resolving their difficulties. One favorite technique is to look for exceptions when problems have not been present or have been overcome. Another has been to nurture and help clients notice small changes from which they can build larger ones. De Shazer asked clients to observe what happens in their lives that they want to continue. De Shazer and colleagues also employ the “miracle question,” stated as: “Suppose one night, while you were asleep there was a miracle and this problem was solved. How would you know? What would be different?” All these techniques are designed to help clients begin to think in terms of solutions and the ability to resolve difficulties rather than in terms of problems and a person’s difficulty in resolving them.


Solution-focused approaches have been among the most widely influential family therapies in the past decade. The positive focus and optimistic frame of these models has proven most welcome to families and therapists alike. Criticism has focused on the repetitive use of the same few interventions (e.g., the miracle question), and on the simplistic notion of problem development and resolution implicit in the model. Unfortunately, given their promise, solution-focused approaches remain among the least studied of the family therapies.


Cognitive-Behavioral Approaches


Cognitive-behavioral models extend cognitive-behavioral principles to the treatment of family systems. These models have primarily been utilized in work with child behavior problems (especially conduct disorder and delinquency) and with difficulties encountered by couples (especially marital dissatisfaction). Cognitive-behavioral methods begin with the assumption that thoughts and behavior are crucial to all aspects of functioning and that the most efficacious pathways to change directly address dysfunctional thoughts and behavioral patterns.


Classical and operant conditioning are the central mechanisms for shaping behavior in a behavioral paradigm. Operant conditioning has assumed particularly great importance in behavioral parent training aimed at child problems. Humans are seen as inevitably affected by the reinforcements they receive. However, cognitive-behavioral family therapy is not fully the product of classical learning theory, but instead is derived from its application in the social context (called social learning theory) where social reinforcers assume great importance. Social learning occurs both directly from experiences that reinforce or punish and indirectly through processes such as modeling, in which learning occurs through observation of contingencies.


Social exchange theory also has had a prominent place in cognitive-behavioral approaches. Social exchange theory suggests that individuals strive to maximize their outcomes to increase the rewards they receive and to decrease the costs. Behavior from one person is viewed as likely to be met with reciprocity from another, so that positive behavior leads to positive behavior, and punishment to punishment on the part of the other. In particular, couples are regarded as likely to develop social exchanges that can become mutually supportive (each emitting positives to the other) or coercive (each emitting punishing behaviors).


Similar to the individual variants of CBT, problem behavior is viewed as primarily the product of either skill deficits that stem from a lack of knowledge, or from the establishment of coercive exchange. Skill training provides the knowledge and experience needed to engage in appropriate social behaviors whether as a spouse or as a parent. Positive exchange is altered directly by helping clients become more aware of patterns of exchange and by negotiation of a more satisfying quid pro quo.


The cognitive theories that make up the cognitive part of CBT emphasize the development and maintenance of dysfunctional or irrational thought processes and direct efforts to alter these cognitions through learning in therapy. Cognitive interventions examine the ideas that lie behind behavior and emotion for the presence of core distortions. The emphasis lies in being able to understand the importance of the thought that lies between an experience and the resultant feeling. Cognitive interventions principally help clients to understand and alter the tendency to overgeneralize, personalize, or be overly negative about events that are occurring. Homework is essential in tracking and assessing beliefs, just as it is essential in accomplishing behavioral goals (Epstein & Baucom, 2002).


The early version of cognitive-behavioral couple and family therapy emphasized mostly behavioral principles with little consideration of systems theory. It was not unusual during this time for behavioral family therapists to meet exclusively with parents to train them in better parent practices to shape the behavior of children. More recent work by cognitive-behavioral therapists has incorporated a systemic emphasis in their work (Christensen & Jacobson, 2000). Patterson and Chamberlain (1994) have clearly described the reciprocal coercive influences of child and parent in conduct disorder and have demonstrated that therapists who too frequently engage in teaching behaviors promote noncompliance with therapeutic tasks. Sexton and Alexander (2005) in functional family therapy have added the strategic notion of grasping the function of behavior-to-behavior analysis. In functional family therapy, attention first centers on identifying the function of behavior, and then, only once these functions are identified, cognitive-behavioral interventions are introduced to help the family successfully fulfill this function in a less damaging way.


Cognitive-behavioral therapies are more similar to one another than other groupings of family therapies, such as strategic or intergenerational. A strength of CBT is that the work of each theorist builds on that of others. Even if models have different names and slightly different components, they utilize similar technologies for treating specific problems. Couples therapies are like one another, as are treatments for children and adolescent problems.


Weiss and Halford (1996), Jacobson and Margolin (Jacobson, 1987; Jacobson & Margolin, 1979), and Stuart (1969) all have articulated similar approaches to couples therapy based on social exchange and skill development. Each approach begins with a behavioral assessment that includes the use of instruments to assess general levels of relationship satisfaction, such as the Dyadic Adjustment Scale. However, the primary focus of the assessment is on delineating problematic exchanges, specific target behaviors, and themes in the relationship that require change, evaluated through client recording of these behaviors between sessions, therapist observation of typical interactions, and clients completing self-report forms. The results of the assessment are directly shared with the couple, highlighting the areas in their relationship that require attention, leading to the development of a plan for change. Much of couple dissatisfaction is seen as the product of the low level of positive reinforcement and the high level of coercive exchange in the relationship, an often-replicated finding in maritally distressed couples.


A wide range of interventions is utilized to address such problems. Monitoring of behavior, through tracking and sometimes including the use of videotaped feedback, help couples objectify their behavior and see it from the perspective of an outsider. Where specific skills are lacking, skills training is employed to develop competencies such as the development of communication skills (e.g., attending, reflecting, listening, and speaking) and problem-solving skills (e.g., the abilities to define problems, generate alternative solutions, and reach naturally satisfying outcomes). Behavior exchange is specifically addressed through the development of contracts between the parties about these exchanges, most based on a quid pro quo, in which the behavior of one party is directly exchanged for the behavior of the other. Therapy seeks to move couples to the five-to-one ratio of positive to negative exchanges of satisfied couples (Gottman, Driver, & Tabares, 2002). More recently, the examination of couple cognitions about the relationship has also come to occupy a prominent place in cognitive-behavioral approaches (Epstein & Baucom, 2002), especially unrealistic beliefs about expectations for the relationship that intrinsically limit couple satisfaction.


Behavioral couple treatments have a particularly strong record of demonstrating success in empirical studies, at least in short-term effectiveness (Lebow & Gurman, 1995). The conundrum for cognitive-behavioral couple therapy lies in addressing the aspects of relationship that are not simply about behavior, but about feeling states, particularly love and caring. Behavioral couple therapists have therefore stretched the model to accommodate the obvious importance of this aspect of relationship. In early formulations, some form of noncontingent loving behavior was prescribed, called caring days or love days. More recently, Christensen and Jacobson (2000) have emphasized the importance in their integrative behavioral couples therapy of developing accepting behaviors in addition to other skills.


In sex therapy, a range of specific techniques for dealing with sexual problems are added to couple therapy (McCarthy, 1989; McCarthy & McCarthy, 2003). Typical sex therapy has a behavioral focus but also includes some other interventions, as in Helen Singer Kaplan’s (1995) and Barry McCarthy’s (1989) widely circulated integrative models. Much of the behavioral core of these approaches developed by Masters and Johnson (1976; McCarthy, 1973) derives from the well-demonstrated insight that anxiety is antithetical to sexual response, but through classical conditioning, relaxation can replace anxiety. Sex therapy almost invariably includes the use of what are termed sensate focus techniques to induce relaxation. Other specific techniques are specifically tailored to each sexual dysfunction. Sex therapy numbers among the most effective therapies in outcome studies although the rates of success reported recently are considerably lower than those originally reported by Masters and Johnson (LoPiccolo & Van Male, 2005).


Much of the treatment of child problems in behavioral family therapy has exclusively focused on intervention with parents through behavioral parent training (Kazdin, 2005). Given the theoretical orientation emphasizing reinforcement as crucial in behavior, and the large body of data available suggesting that the parents of problematic children help shape their dysfunctional behavior and respond poorly to it, many behavior therapists have concluded that time in therapy is best spent with the parents who control the reinforcers rather than with the children, especially when children are small. As in behavioral couple therapy, parent training begins with an assessment phase in which patterns of thought and behavior are recorded and connected to the target behavior of concern. This leads to a functional analysis of the problematic behavior from which a plan is formed specifying the skills that need to be mastered and changes in contingencies that need to occur for the problem to be improved. Focus centers on parental caring as well as on establishing control. If the problematic behavior on the part of the child is restricted to a single area of concern, specific contingencies may be created in response to that behavior (e.g., a program may be constructed of reward for schoolwork). When problems are encountered in a number of areas, more comprehensive contingency programs are developed. Home token economies and point systems provide ways for credit to accrue for positive behavior and to be subtracted for problematic behaviors, with rewards dispensed for overall performance. In all programs, the preference for positive reward over punishment in shaping behavior is emphasized.


In the treatment of the most difficult children and of adolescents, behavioral parent training has been augmented with other intervention strategies. For example, Alexander and Sexton (2002) have developed functional family therapy for adolescent delinquent behavior with an emphasis on examining the function of behavior. In the approaches of Patterson (Patterson, Reid, & Eddy, 2002) and Henggeler’s multisystemic therapy (Borduin, Henggeler, Blaske, & Stein, 1990), the behavior of the child or adolescent and the impact of peer groups and other relevant systems is accorded equal attention to the behavior of parents.


Behavioral family approaches to child and adolescent problems are among the most researched and validated of psychotherapies (Lebow & Gurman, 1995).


Psychoeducational Approaches


Psychoeducational approaches to the treatment of serious mental illness are based on the notion that such syndromes as schizophrenia and bipolar disorder seriously impair functioning and that it is helpful for families to learn about these disorders and the family patterns that are most useful in their amelioration. Sometimes, illness models are fully incorporated as part of these approaches, whereas in other variants such a model is presented to families as one of several possible explanations for the disorder. The goal of these treatments is to establish a collaborative partnership with families, providing them with the most needed information and skills. Beyond this constant, psychoeducational treatments include an eclectic mix of interventions derived from individual and family therapy that have particular relevance to the particular syndrome, as well as psychopharmacological interventions.


Psychoeducational family treatments were first developed in the context of schizophrenia, where a group at Western Psychiatric Institute in Pittsburgh (Anderson, Reiss, & Hogarty, 1986) and another at University of California, Los Angeles (UCLA; Falloon, 1988) developed related although somewhat different psychoeducational methods. Each featured medication for the person with schizophrenia, along with education for the family. Each also highlighted the now frequently replicated finding that people with schizophrenia remain highly reactive to expressed emotion in those around them, a combination of criticism and high emotional arousal.


The Pittsburgh group’s unique contribution lies in what they termed survival skills workshops that, over a full day, present the current state of knowledge about schizophrenia to families. These workshops seek to impart information, increase the sense of social support, and reverse the negative interaction families of disturbed individuals often have with mental health providers. Families are regarded as full collaborators and taught in these workshops both what is known and what is speculative about schizophrenia.


The Pittsburgh model also accented work in therapy designed to alter dysfunctional aspects of family structure and a minimalist approach to intervention in sessions that included the schizophrenic, with one constant goal being to keep expressed emotion to a minimum. The methods of the UCLA group also seek to involve family and reduce expressed emotion, but place greater emphasis on behavioral skills training, bridging psychoeducational and CBT approaches. There also is a greater emphasis in this model on crisis management when the inevitable crises develop in the lives of these families. Both the UCLA and the Pittsburgh groups reported remarkable improvements in outcomes such as recidivism in sophisticated clinical trials. This work has been followed up with similar procedures for families dealing with bipolar disorder (Miklowitz, 2002).


One striking aspect of these models has been the inclusion of family in the treatment of these disorders in a way that has proved highly acceptable to these families, in contrast to earlier methods of dealing with these families that left many families feeling blamed and highly dissatisfied. Much of this earlier work questioned the very existence of mental illness or even of disturbed internal processes in the schizophrenic. Some (Haley & Schiff, 1993) even suggested that medication for the schizophrenic is harmful because it further establishes the patient in the sick role and obscures what were regarded as the inevitable systemic issues. The strong evidence for the efficacy of psychoeducation, coupled with the lack of evidence that family therapy works in these samples without the use of medication, suggests that the psychoeducational form of family therapy is clearly superior to the earlier variety. It appears clear that the highly stimulating family therapies of these early days of family therapy in treating schizophrenia provided exactly what is not needed: a highly stimulating environment likely to be difficult for the patient and an environment in which families are likely to feel blamed for the problem. All told, for schizophrenia and other severe mental disorders, psychoeducational treatments number among the most successful family therapies and are becoming widely disseminated as part of the standard for care.


Bowen Therapy and Other Intergenerational Approaches


Murray Bowen (1978) developed a prominent form of family therapy (now called Bowen family systems therapy) that incorporated systems theory, along with an intergenerational focus. The crux of the Bowen approach lies in the concept of what Bowen termed differentiation of self, which essentially amounts to the ability to distinguish thoughts and feelings. For Bowen, psychological and systemic health is a direct function of the level of differentiation. When individuals differentiate themselves from family processes, they are viewed as less susceptible to the pathology inducing aspects of the system. Differentiation is clearly distinguished from cutoff (the establishment of rigid boundaries that minimize contact with family), which is viewed as innately problematic.


In Bowen’s theory, individual development is largely shaped by the family system. Bowen envisioned an “undifferentiated family ego mass,” of beliefs and feelings in families that are transmitted through what he termed a family projection process across generations. The position of the individual in the family, in part determined by birth order and in part by other factors, also is viewed as of key importance in shaping the individual. A key element of family process lies in the presence of triangles, in which the interaction between two individuals is affected by the presence of a third. Triangles are viewed as inevitable in family life but also as treacherous for individual development.


In Bowen family systems therapy, each member of the family involved in treatment is coached on how to better differentiate themselves from present and old family patterns and how to manage his or her anxiety. Much of the work focuses on the relationships adult clients have with their families of origin. Family of origin is typically not seen directly in treatment, but the interactions with families are examined through forays outside of the session in which the client learns about family histories and processes, experiences these processes, and tries out new ways to cope with them. Exploration involves both direct contacts with living relatives and efforts to learn about and experience feelings in relation to deceased family. Genograms, diagrams of the multigenerational family systems of participants, are employed to help in this examination to shape exploration and to set goals. Because this is the essential process of treatment, much of Bowen family systems therapy is conducted with only a single client in the office although the work is principally centered on his or her family relationships.


Bowen family systems therapy represents a bridge between individual and family therapy. Although couched in systemic terms, many of Bowen’s ideas about differentiation resonate with the concepts of object relations and cognitive models of therapy. Bowen developed a method that has enabled an exciting and moving voyage of exploration of family processes by innumerable clients. Although the clinical experience of many family therapists suggests that this is a highly satisfying and effective treatment for clients, there has unfortunately been a paucity of research investigation of this approach.


Several other approaches have centered on the examination of intergenerational process beyond that of Bowen. The contextual approach of Ivan Boszormenyi-Nagy and colleagues (Boszormenyi-Nagy et al., 1991) looks at relationships in what he terms invisible loyalties. Their work aims at exploring multigenerational processes in families with an eye to what they term ledgers, the balance of what has been given and received by each individual. The central tenet of the therapy lies in helping clients deal with and balance the ledger they bring from their families of origin. The stance of the therapist toward the family, termed by Boszormenyi-Nagy and Spark (1973) as multidirected partiality, is also much like the hovering attention basic in more recent psychoanalytic approaches, but it is carried over to the family context providing support for each family member with new language and intervention strategies.


Other intergenerational approaches focus on creating family rituals that can serve as cathartic events for negotiating the emotional turmoil resulting from multigenerational legacies (Imber-Black, 1991).


Psychodynamic Approaches


Although psychoanalytic formulations often served as the foil in expositions of early family therapists against which the value of focused systemic therapies could be highlighted, there also has been a long-standing tradition of family therapies that have incorporated psychodynamic concepts (Gurman & Jacobson, 2003). Early in the history of family therapy, Ackerman (1970), Framo (Framo, Weber, & Levine, 2003), Sager (1967), Stierlin (Stierlin, Simon, & Schmidt, 1987), and others created treatments that blended systems concepts with specific psychodynamic theories. More recently, the refinement of object relations concepts in psychoanalysis has led to the emergence of several family therapies that take object relations one step further, considering those dynamics directly in the context of the family in treatment (J. S. Scharff & Bagnini, 2002; J. S. Scharff & de Varela, 2000).


Psychodynamic family approaches share a number of common characteristics, despite the considerable variation in the particular psychodynamic formulation included. Most basic to psychodynamic formulations in couple and family therapy is the notion of an active dynamic internal process in individuals. Psychodynamic approaches share the belief that unconscious mental processes are important and that early experience has a crucial influence on later behavior and experience. Psychodynamic therapists also emphasize maintaining the frame of treatment, the formal arrangements such as frequency, time, and length of sessions. Creating an appropriate frame is viewed as leading to the development of a holding environment (D. E. Scharff & Scharff, 1987) in which the therapist tolerates client’s anxieties and tensions while remaining empathic with his or her emotional experiences. Another important route into unconscious process is the understanding of transference—the clients’ displacement or projections onto others of feelings, impulses, defenses, and fantasies from important past relationships or conflicts. These projections help recapitulate important aspects of clients’ earlier relationships in therapy or in the family relationships. In psychodynamic couple and family therapy, transferences are observed as much in relation to other family members, particularly spouses, as in relation to the therapist.


Psychodynamic couple and family therapies also accent the therapist’s awareness of his or her own feelings in the therapy process. Countertransference, the therapist’s reactions to the client based on client transferences or on the therapist’s own personal experience, is viewed as an important source of information about client process. Most important, in projective identification, the therapist may be induced to feel or behave as others have behaved and felt toward the client. In most psychodynamic couple and family therapy, the understanding and owning of projective identification on the part of the client assumes an especially important place in the process.


Psychodynamic family therapies also accentuate the importance of interpretations that provide meaning to behavior by explicating unconscious processes. Change is seen as the product of working through a person’s issues over time. Understanding resistance, the process often rooted in anxiety that moves against therapeutic goals, is also viewed as essential to enabling change.


James Framo (1992) developed what he termed family-of-origin sessions as part of his couple therapy, in which the partners in the therapy would meet for a few sessions with members of their own family of origin to understand better and resolve the outstanding issues that derive from that experience. This approach utilizes sessions with the family of origin to further the clients’ exploration of internal conflicts.


Although pure-form psychoanalytic therapies are relatively infrequently encountered in couple and family therapy, psychodynamic principles are central in the practice of many family therapists, especially in the integrative therapies (see later section). Psychodynamic therapies have rarely been evaluated through research. The demonstrated effects of one variant of psychodynamic therapy, insight-oriented couples therapy (Snyder & Wills, 1989), suggests the likelihood of a promising future for these treatments in research, should this research ever be carried out.


Experiential Approaches


Prominent experiential couple and family therapies have been developed by Whitaker (Whitaker & Bumberry, 1988), Satir (1988), and Greenberg and Johnson (1988; Johnson, 1996). Each of these approaches places the emphasis on the felt experience of the clients, accentuating the healing power of emotional moments in therapy for restoring a sense of liveliness and connection.


Each experiential family therapy employs different intervention strategies. Whitaker utilized a wide array of techniques, ranging from provocative commentary on the family’s life and conflicts to physically wrestling with clients, all aimed to fight emotional deadness. Satir developed exercises associated with the human potential movement such as family sculptures in which family members are moved around to depict relationships in the family and trust building. Greenberg and Johnson in emotionally focused therapy, and Johnson in her later work incorporating attachment theory in emotionally focused couples therapy, draw from and build on methods derived from Gestalt therapy in which strong emotions such as anger are expressed, defenses emerge, and work with the clients looks to allow for a softening of feelings that can promote a restoration of connection. Although their schools of approach largely have not lasted beyond their lifetimes, Whitaker and Satir remain enormously influential to the practice of family therapy, especially in drawing attention to the importance of the person of the therapist and the need to maintain liveliness and authenticity in couple and family therapy. Emotionally focused couples therapy has become well established both as an evidence-based treatment and as a popular method of practice.


Narrative Approaches


Narrative therapies are the fastest growing segment of family therapies. Michael White (White & Epston, 1989) has emerged as the major figure in the narrative movement. Other prominent figures include Anderson and Goolishian (1988, 1992), and Hare-Mustin (Hare-Mustin & Marecek, 1989; see Chapter 6 for a more complete discussion of these models that bridge individual and family therapy). These approaches vary in their specifics, but all have roots in the core idea that life is largely constructed through the stories people tell themselves about their lives. An important variation is termed social constructivism (Gergen, 1985), the notion that knowing is socially constructed through language and discourse and depends on the context of the observer. Narrative approaches emphasize thought processes and beliefs, not as cognitions to change, but as individual stories that have been socially created and that can be collaboratively reconstructed.


White highlights interventions deigned to externalize problems (i.e., seeing them as separate entities from the individuals involved). Much like solution-oriented and MRI therapists, White also emphasizes the outcomes that occur when individuals have been successful in overcoming problems. Problem-oriented descriptions are replaced by stories of accomplishment. Anderson and Goolishian (1992) offer the ultimate extension of this type of approach, fully replacing the notion of the expert therapist with the idea of therapist and clients as fully coequal partners in conversation. Rather than merely opening discourse, these approaches also accent the freeing of repressed voices and promote social justice. For White and many others in the narrative movement, following Foucoult, the dialogue needs to be as much about overcoming societal oppression as about family process.


Although sometimes these therapies do involve seeing families conjointly, much of the work is done with individuals. As yet, we also have little in the way of outcome research testing the effectiveness of these models. However, narrative models have already gained many proponents and have broadly influenced family therapists toward a greater emphasis on a coequal collaborative conversational style and that deemphasizes the therapist’s role as expert toward a greater emphasis on the client’s voice and toward helping clients revise stories about their lives to create more workable realities.


Integrative Approaches


Integrative methods have become commonplace in couple and family therapy, typically crossing the boundaries of individual, couple, and family therapy. Not only has a considerable literature emerged concerned with integration (B. Baucom, Christensen, & Yi, 2005; Lebow, 1984, 1987a, 1987b, 2003, 2006a; Pinsof, 1995), and numerous integrative models developed and widely disseminated (Gurman, 1992; Liddle, Rodriguez, Dakof, Kanzki, & Marvel, 2005; Pinsof, 2005b), but the movement to integration has become so much part of the fabric of family therapy that it largely goes unrecognized.


Integrative models merge the raw material of the various approaches (see Chapters 12 and 13). This merger occurs at three distinct levels: theory, strategy, and intervention. Because there are numerous therapies to merge, and several levels along which to merge them, integrative models vary enormously in content. Some integrative approaches accent each therapist’s building of a personal method (Lebow, 1987a), whereas others offer highly prescriptive delineations of therapeutic ingredients and a specific map for when to do what, such as integrative behavioral couples therapy (Christensen & Jacobson, 2000) for marital distress or multidimensional family therapy for adolescent substance abuse (Liddle et al., 2005). Other models, such as Pinsof’s problem-centered therapy (Pinsof, 1995) or Gurman’s integrative marital therapy (Gurman, 1992), bridge this chasm through prescribing ingredients, but allowing varying levels of room for improvisation, especially for more advanced practitioners.


Most integrative efforts combine behavioral notions of learning, with a systemic understanding of the family process, and individual psychodynamics. Pinsof’s (1995) problem-centered therapy offers a highly refined version of this type of model, in which self-psychology is the internal system. Gurman (2002) has developed a combination of object relations, behavioral, and systemic procedures for working with couples.


Much of the recent creative edge in integration has been concerned with the development of specific treatments for specific populations. Goldner, Penn, Sheinberg, and Walker (1990) have merged feminist, narrative, systemic, and psychodynamic concepts in the treatment of abuse within couples. Multidimensional family therapy (Liddle et al., 2001), functional family therapy (Alexander & Sexton, 2002), and multisystemic therapy (Letourneau, Cunningham, & Henggeler, 2002) have brought structural, systems, and behavioral principles together along with a developmental perspective in the treatment of adolescent chemical dependency and delinquency. Similarly, Kaplan (1974) has created an integrative approach to sex therapy; Rolland (1994) to families with physical illness; and Scheinberg and Fraenkel to child sexual abuse (Sheinberg, True, & Fraenkel, 1994).


Feminists (Goldner, 1985) and those who offer treatment in diverse cultures (Boyd-Franklin, Franklin, & Toussaint, 2000; McGoldrick et al., 1991) have focused attention on the obvious importance of race, class, and gender and on the value of therapists’ shaping treatment in relation to these factors. This has resulted in the development of several integrative family treatments, specifically designed for particular cultural groups or gender-related issues (Boyd-Franklin, 2003; Szapocznik et al., 1986). These models move beyond the notion of one method for all to a better understanding of which methods work best in what combination with various populations. Culture and gender have also been incorporated as anchors in broader efforts at integration such as the metaframeworks model (Breunlin & MacKune-Karrer, 2002) that chart universal frameworks that appear across family therapies.


Many of the integrative methods described earlier have developed in research programs and these number among the best validated of family therapies (Henggeler, Clingempeel, Brondino, & Pickrel, 2002; Liddle et al., 2005; Santisteban et al., 2003). There also remain many as yet untested integrative models.


ASSESSMENT PROCEDURES


Couple and family therapies center on a relational viewpoint. There is both a broader and more limited version of the relational viewpoint: In the broader versions of the relational viewpoint that were most prominent early in the history of family therapy, the relational perspective was offered as a radical contrast to the individual view. First-generation family therapists pictured the systems in which people lived as having such powerful properties that they were viewed as the essential determinant of individual thoughts, feelings, and behavior. From this vantage point, what was occurring at the level of the individual was insignificant, and therefore clinicians did not need be concerned with whether an individual was depressed, anxious, or schizophrenic. Individual personality and disturbance and, therefore, individual assessment was seen as of little use. What mattered from this view were the roles individuals filled and how their behavior played out in interactional cycles, which could best be addressed through assessment of interactions.


These bold thoughts of a new paradigm helped move attention toward relational assessment and diagnosis. However, the complete rejection of individual assessment was not warranted. The radical position taken stemmed from ideology, not the data about families. Indeed, the brilliant ideas about systemic impacts were developed without a well-validated method for assessing interactional processes. Assessment had to depend on the eye of the observer and therefore remained subject to considerable bias. Those who could not see the presence of powerful individual factors did not notice their impact. But what remained was the brilliant insight of the incredible impact and importance of relationships. Many years of family research has confirmed and reconfirmed the power of this influence.


More recently, a more mature science-based view of relational diagnosis presents systems assessment not as a complete rejection of individual assessment, but as an additional dimension for assessment, which is equally as important as individual assessment. A complete understanding must consider both interactional factors and family and other system processes. The present vantage point allows that individual functioning does make a difference, but that individual functioning is inevitably interwoven in a circular process with interactional processes. The present version of the relational viewpoint also suggests that there are a number of conditions and difficulties for which relational diagnosis assumes greater importance than individual diagnosis. For example, the evidence overwhelmingly suggests that couple satisfaction and its flip side, marital maladjustment, are far more a product of what occurs in the relationship process between individuals than of the particular characteristics of the individuals.


The development of the relational viewpoint has led to efforts to describe pathology from a relational perspective. At one level, this has led to the development of relational nomenclatures, describing interaction patterns that are problematic. Just as the DSM-IV offers the criteria for individual diagnosis, a similar list of criteria can be offered for problematic relational patterns whether they are marital difficulties, triangulation between parents and children, or family violence. In parallel with this form of diagnosis has been the development of measures that tap interpersonal processes.


PROCESS OF PSYCHOTHERAPY


As has been described earlier, couple and family therapies vary enormously from one another and the techniques utilized vary considerably from treatment to treatment. Yet, there is ultimately more in common that transcends couple and family therapies than that which differentiates them from one another.


Couple and family therapies almost invariably share the presence of more than one client in the room at a time. These therapies thereby all typically pay considerable attention to the generation and maintenance of a therapeutic alliance. One consideration is that typically someone in treatment has been brought into the treatment rather than being the one who initiates the treatment. Alliances are also more complex than in individual therapy and include the individual alliances each party has with the therapist as well as the collective couple or family alliance with the family (Pinsof & Catherall, 1986).


Couple and family therapies are also typically brief therapies. Although there are some variants of long-term couple and family therapy, the complex alliances involved and the pragmatics of organizing treatment almost invariably lead to treatment being less than 20 sessions. Therapists also share an active style of treatment although the specific content of the style varies considerably. Some therapists accentuate interventions to change structure, others cognitions and behaviors, others affect, and yet others object relations. Nonetheless, there has emerged a set of interventions that are typical in a wide range of couple and family therapies. These include reframing, behavioral contracting, psychoeducation about family life, problem solving, direct interventions to change family structure to be more functional, and the use of genograms to help understand multigenerational family patterns. As noted earlier, the practice of couple and family therapy is becoming increasingly integrative (Lebow, 2003, 2005a). Medication is employed as an adjunct in many couple and family therapies aimed to address specific difficulties in functioning, as are individual treatment sessions and interventions in larger systems such as schools or communities (Breunlin, Schwartz, & Kune-Karrer, 1992).


CULTURE AND GENDER


Today’s approaches to couple and family therapy are strongly influenced by understandings of the importance of gender and culture. As noted earlier, the feminist critique of early forms of couple and family therapy has been highly influential (Goldner, 1991). Couple and family therapists work to incorporate both the understandings that men and women bring to relational life and the limits imposed by those understandings (Levant & Silverstein, 2001; Rampage, 1995). Furthermore, couple and family therapists must constantly expand their perspectives in relation to the diverse family forms that make up our society, including families with one parent and gay and lesbian families (McGoldrick, 1998). Couple and family therapy also depends on understanding the influence of culture on family (McGoldrick, 1998). Aspects of how family relationships work best are shaped by culture.


EMPIRICAL SUPPORT


Three decades of research have pointed to the effectiveness of couple and family therapy. Reviews of the literature conclude that the outcomes achieved by those receiving couple and family therapy are better than those not receiving treatment (Alexander, Sexton, & Robbins, 2002; Lebow & Gurman, 1995). With more and better recent research emerging in the past few years, the evidence for effectiveness has become unequivocal. Although the majority of studies have focused on behavioral treatments, there now also is a considerable base of other treatment studies that point to treatment efficacy (Johnson, 2003).


There are differences between the amount of evidence supporting the efficacy of the various couple and family therapies (Lebow & Gurman, 1995). Cognitive-behavioral approaches have extensive bodies of research support, particularly in treating childhood and adolescent conduct disorder, marital dissatisfaction, and adolescent acting out. Structural approaches in their incarnations in treatments such as brief strategic family therapy also have considerable support, particularly in treating adolescent conduct disorder (Perrino, Gonzalez-Soldevilla, Pantin, & Szapocznik, 2000; Szapocznik & Williams, 2000). An experiential approach to couple therapy, emotionally focused couples therapy (Johnson, 2003), and a psychodynamic approach, insight-oriented couples therapy (Snyder & Wills, 1989), also have garnered research support. A considerable body of research evidence indicates the efficacy of treatments that integrate individual and conjoint treatments, including psychoeducational treatments of schizophrenia (Anderson, Reiss, & Hogarty, 1986), multisystemic therapy (Henggeler, 2003) and functional family therapy for adolescent delinquent behavior (Sexton & Alexander, 2002), and multidimensional family therapy for adolescent drug abuse (Liddle et al., 2005). In contrast, there exists very little research support for a variety of widely practiced couple and family therapies including Bowen, narrative, strategic, and solution-focused approaches. Differences in our knowledge about the impact of various models now become more pronounced each year.


Looked at from the perspective of the presenting problem, couple and family therapies have been demonstrated to have considerable value in treating depression, anxiety disorder, panic disorder, schizophrenia, alcoholism, and marital maladjustment in adults, as well as conduct disorder, autism, and drug abuse in children and adolescents (Lebow & Gurman, 1995; Pinsof & Wynne, 1995). In most instances, this research has studied assessing the impact of family therapy on specific disorders actually has examined couple and family therapy in combination with other interventions such as individual sessions with the client with the disorder.


Couple and family therapies also are the only demonstrated effective means for impacting couple and family issues (e.g., couple distress and family conflict). Frequently, it appears that even a small amount of family involvement adds immeasurably to treatment effectiveness and increases acceptability and participation in treatment (Lebow & Gurman, 1995).


On a more negative note, there are indications that treatments diminish in their effectiveness over time (Jacobson, 1989). Although outcomes are quite impressive in the short term, effects often dissipate.


An outstanding body of research is now also available that informs practice in illuminating family process and family development (Lebow, 2006b). For example, Gottman and associates have carried out several studies that have added immeasurably to our knowledge of patterns and sequences of dysfunction in marriage (Gottman, 1999; Gottman & Notarius, 2000), such as showing particular patterns in couples conflict that directly lead to decreasing levels of marital satisfaction and ultimately to divorce. Similarly, powerful bodies of research concerned with such issues as patterns in divorcing and remarried families, family transitions around the birth of children, and patterns in the alcoholic family (Lebow, 2006b) have clear clinical implications.


A few other trends in the research that have emerged in recent years are particularly noteworthy. We are seeing a trend toward more clinical trials research comparing treatments. Paradoxically, recent research also shows the impact the intense study of process can have when focused on a few cases, particularly when the cases are selected by outcome status and the methods for assessing process clearly focus on change events rather than engaging in a hunting expedition. We also are beginning to see a great deal of research on treatments that transcend the labels individual, couple, or family therapy, just as clinical methods are moving to transcend these boundaries (Lebow 1987a, 1987b). We are also seeing more efforts to be conscious of gender and culture in research. No longer is the assumption made that findings necessarily generalize across genders or cultures. Perhaps most promising, family therapists and family researchers have recently begun to engage in dialogue, suggesting that the notable gap between research and practice may narrow (Lebow, 2006b).


GENERIC INTEGRATIVE FAMILY THERAPY


My approach to couple and family therapy is based on a multilevel biopsychosocial understanding of human functioning (Lebow, 1997, 2002). Problems and strengths are seen as residing on multiple system levels within individuals (biological, cognitive, affective, psychodynamic) and on various social system levels (couple, family, peer, society). Rather than viewing each problem as uniquely nested in a single individual or in a relational subsystem, difficulties are regarded as typically having manifestations across a range of these system levels.


As part of this view, there is no one “right” approach to working with clients. Instead, multiple ways of intervening are seen as likely to be viable and useful for the same couples and families. Therefore, the prime task of therapy becomes the negotiation of a treatment plan that fits with clients’ goals and with their sense of what is most acceptable to them within the range of treatment strategies likely to be effective for dealing with their presenting difficulties. For some clients, the primary goal is symptom change, but for many clients (perhaps the majority of clients) other goals, whether they are goals of better relational or individual functioning or better self-understanding, are most in focus.


My approach is not based on one or two theories of personality and/or the change process, but it has its foundation in a generic view of psychotherapy (Orlinsky & Howard, 1987) and draws from a wide array of therapeutic strategies and techniques (Lebow, 1987a). This therapy also views success in couple/family relationships as depending more on blending the idiosyncratic goals of the two partners or family members, rather than manifesting one set “successful” ways of being part of a couple or family. From this view, there are some patterns that inevitably lead to difficulty, but many possible roads to satisfied relationships.


Focus of Treatment


Couples and families seek help for many reasons; some having to do with reducing relationship distress, and others for motives ranging from wanting to dissolve a relationship, to hoping for constructive relationship development, to coping with life crises, to searching for help with specific individual problems. My version of integrative couple and family therapy prioritizes the problems that are of greatest concern to the family.


In this treatment, the couple/family therapist makes a series of complex clinical decisions about what to focus on and when, where, and how to intervene. Following a tenet of Pinsof’s integrative problem-centered therapy (Pinsof, 1995), all family members are viewed as part of the client system, but who participates in sessions varies based on the specific goals set in that case. Session formats are chosen based on an algorithm for which session formats impact most in relation to particular kinds of problems based on the findings from research and clinical experience. In family therapy, a strong argument can be made for many sessions in every possible treatment format: family, couple, other subsystem, and individual sessions. Almost always, however, resources are limited and pragmatic decisions about the choice of modality are made based on what constitutes effective intervention in similar cases.


Client acceptability of treatments is an essential ingredient in choices of who to include in treatment, the level of the system on which to focus, and the framework in which to intervene. Collaboration is established about each of the pragmatic choices in the treatment; for example, who will be in treatment and whether treatment will focus on the level of biology, behavior, cognition, affect, or internal process. As Pinsof (2005a) has suggested, each effort at intervention can be regarded as an experiment. When strategies fail, this information becomes further leverage to convince clients to engage with further strategies of change.


Family members also differ in their expectations, and conjoint therapies largely focus on working with and negotiating these expectations. The balance between acceptance and behavior change is determined by a combination of what family member’s expectations are and what can and can’t be readily changed.


Assessment and Diagnosis


Assessment is a crucial facet of my integrative couple/family therapy. The most important aspects of assessment are to be able to grasp clearly the problem as stated by various family members and to understand it from a biopsychosocial perspective so as to be able to identify the most efficacious and acceptable routes to accomplish the goals clients have in therapy. Assessment is an ongoing process that begins with the first contact therapists have with the family. Initial phone contacts help in formulating hypotheses about useful formats for the first meeting or meetings. Early in treatment, the therapist develops a blueprint for the change process, yet this is ever evolving. Following Pinsof (1995), assessments are not seen as fixed and unchangeable, but rather the reactions of clients to various treatment strategies is viewed as providing information that will add to the assessment and possibly alter the blueprint.


Assessment considers each system level: family, couple, other subsystems, and individual. Individual behaviors are viewed in the context of the interactional pathways in which these behaviors are nested. Yet, individual personality typically also exercises a potent effect, and individual contributions also remain in focus. Ultimately, it is a crucial aspect of the assessment to determine how much of the problem is rooted in individual behavior and how much in family process.


Assessment also focuses on what is occurring across a number of system levels: social, family, biological, behavioral, cognitive, emotional, and dynamic internal process. If a family reports a great deal of acrimonious arguing, assessment would focus on such factors as the culture of the family (how acceptable or unacceptable is this way of acting?), the family structure (what alliances and bonds are formed or severed as a result of the ongoing battle?), circular pathways (how one person’s behavior prompts what behavior in the others), behaviors (who fights with who and what fighting techniques are utilized?), cognitions (what are the causal attributions and judgments made?), emotion (what each client feels), and internal processes (to what extent is each individual able to manage and tolerate fighting and conflict and what does fighting mean to each family member?). Self-report measures are viewed as valuable tools for screening and for more specific assessment of particular behaviors in treatment. The measures gathered are also used to track change over time.


Intervention Strategies


Intervention strategies flow from what emerges in the assessment. My integrative couple and family therapy draws on some aspect of most of the treatment strategies suggested earlier in this chapter. Treatment centers on utilizing the most efficacious, acceptable, and appropriate treatment strategy for a particular situation.


Psychotherapy research indicates that in almost every venue where psychoeducation is employed, it is useful. In couple and family therapy, clients often do not fully understand aspects of the problems involved or how typically these problems are encountered in contexts such as divorce or remarried families. Presented well, psychoeducation not only enhances understanding but also leads to increased hope for change.


Behavioral methods employed include skill development and the promotion of balanced exchanges between family members. Problem solving, conflict resolution, parenting and communication skills training are almost invariably useful in helping families.


Cognitive and narrative strategies are also incorporated to help family members engage in new ways of thinking about the problems that are occurring. The process goal typically focuses on creating narratives describing events that are less blaming and destructive.


Treatment strategies also incorporate a focus on emotion. When emotion is not expressed, employing such techniques as focusing (Elliott, Watson, Goldman, & Greenberg, 2004), and catharsis can lead to emotional heightening. When emotion is overwhelming, intervention centers on diminishing unprocessed emotion (e.g., anger management).


There also is attention to understanding internal conflicts and the underlying part of interaction that typically is out of the clients’ awareness (Sager, 1976). Typically, this extends into an understanding of multigenerational processes in families and the influence of early experience on present relationships.


All these strategies are not all employed in every case. Methods are chosen for their relevance to specific presenting situations and are incorporated in as synchronous a way as possible, so that one set of intervention strategies builds on another. Although the therapist aims for a multi-level understanding of the problem that incorporates systemic, psycho-educational, behavioral, cognitive, emotion-focused, and psychodynamic factors, intervention strategies are selected based in the likelihood of being helpful in the specific case.


Whenever possible, work focuses on multiple levels of human experience, creating links between psycho-educational, behavioral, cognitive, emotion-focused, systemic, and psychodynamic strategies, so that each strategy is used in the service of reinforcing gains arrived at through the other strategies and/or helping overcome blocks that occur in their implementation and impact. As already noted, at the core of this approach is the notion that there is not only one “right” formulation or effective means for intervening in any specific case. Instead, this approach is about finding a parsimonious approach to attaining the results clients’ desire based on the best knowledge about families and family treatment and on the kinds of strategies most likely to be found acceptable and helpful by the family. Progress in achieving desired outcomes is tracked throughout treatment and the intervention strategy is continually subject to revision based on the progress made.


Treatment Duration


My integrative couple and family therapy as typically brief but also open-ended (Lebow, 1995). The time frame for treatment depends on the kinds of goals in focus and thus therapy can involve only a few sessions or several years, depending not only on the speed with which goals are accomplished but also the kinds of goals set. In this framework, the therapist is seen as analogous to the family practitioner or dentist, forming an alliance with a family and available to help direct problem resolution over the life cycle.


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Jul 12, 2016 | Posted by in PSYCHOLOGY | Comments Off on Couple and Family Therapy

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