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Diagnosing Marital and Family Systems: A Training Model

Author(s): Ronald E. Cromwell and Bradford P. Keeney


Source: The Family Coordinator, Vol. 28, No. 1 (Jan., 1979), pp. 101-108
Published by: National Council on Family Relations
Stable URL: http://www.jstor.org/stable/583275 .
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Diagnosing Marital and Family Systems:
A Training Model*
RONALDE. CROMWELLAND BRADFORDP. KEENEY**

A three part training model in diagnosing marital and family systems is described
covered methodology, theory and clinical implementation. Initially, the training
experience introduces an array of diagnostic tools and techniques. The second unit
focuses on family systems theory and its relation to diagnosis. The third unit inte-
grates the derived theory of diagnosing marital and family systems, termed "sys-
temic diagnosis," with clinical application of a diagnostic strategy with marital
dyads and four member families. Outcomes of the model and suggestions for future
efforts are discussed.

There are expanding networks of clinical there is no formal description of a process


literature related to diagnosis in marital and wherein student clinicians can learn how
family therapy. These include: (a) identifying diagnosis can be systematically applied to
dimensions of family assessment (Kadushin, marital and family systems. This paper des-
1971; Fisher, 1976; Moos & Moos, 1976); cribes an initial attempt to develop a training
(b) identifying and classifying particulardiag- model for facilitating such a learning process.
nostic tools and techniques (Bodin, 1968;
Rationale for the Training Model:
Cromwell, Olson, & Fournier, 1976a, 1976b;
A General Systems Theory Approach
Philips, 1973); and (c) describing the range of
tools and techniques appropriate for "diag- One of the initial problems in designing a
nosing relationships" (Cromwell & Fournier, training experience in marital and family diag-
Note 1). In spite of the availability of this nosis is the lack of a systematic theory of
diverse information concerning diagnosis and diagnosis. Bodin (1968, p. 224) first identified
the growing number of training programs for this problem when stating " . . . there is no
marital and family therapy,' to our knowledge widely accepted conceptual scheme suitable
for family diagnosis in a formal sense. . .
Consequently most family diagnosis is based
*The training model was co-facilitated by the authors on clinical experience and is descriptive of in-
during the Fall 1976 semester as a three-credit graduate dividual cases."
course in the School of Education, University of Missouri- However, the marriage and family orienta-
Kansas City. Appreciation is expressed to Mary Kathleen tion to therapy does not merely suggest a re-
O'Harafor her work as teaching assistant, and to David G.
Fournier for his critical review of an earlier draft of this
vision of past psychological theory and mea-
manuscript. surement. Maritaland family therapy, parts of
**Ronald E. Cromwell is Associate Professor, Child and what Hobbs (1964) has termed "mental
Family Studies, University of Tennessee, Knoxville 37916. health's third revolution," often propose that
BradfordP. Keeney is a Ph.D. candidate in the Department " . . . the unit of study (and treatment)
of Speech and Drama, University of Kansas, Lawrence
66044. should be the social context of the individ-
uals, that symptomatic behavior is adaptive to
IFor a comprehensive review of contemporary training the context, and that if individuals appear to
and supervision In marital and family therapy see the paper differ from one another it is because the situ-
by Liddle and Halpin (1978). ations they are responding to are different"

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(Haley, 1972, p. 14). In its most basic form, first in the area of diagnosis, for without ade-
this view emphasizes that differences be- quate diagnosis there can hardly be adequate
tween "adjusted" people and individuals with therapy."
"psychiatric problems" can best be explained The rationale for the training model pre-
and understood by gleaning an assessment of sented builds upon a general systems theory
their social context. approach which can encompass the diversity
While therapists differ over whether they of diagnostic approaches. Various types of
focus on individuals or larger social contexts, diagnostic approaches are differentiated on
we contend that all marital and family thera- the basis of the level of system to which they
pists engage in some form of diagnosis. In are appropriate. For example, the individual
general terms, whenever a therapist attempts marital dyad, and family unit represent differ-
to derive conceptual order for a given situa- ent system levels. Our emphasis is upon de-
tion, that individual is engaged in the process veloping strategies of diagnosis that take into
of diagnosis. Diagnosis, in this most basic account the various properties of these
sense, refers to one's coming to know a par- systems and their interrelationships. This
ticular situation. Hence, whenever a therapist calls for an integration of general systems
strives to know about a given problematic sit- theory with diagnostic methodology. Keeney
uation, that person can be characterized as and Cromwell (1977) have previously tagged
"diagnosing." Minuchin (1974, p. 131) has this hybrid model, "Systemic Diagnosis."
appropriately noted, "any type of diagnosis is This paper, describes a systematic approach
merely a way of arranging data." to facilitating the learning of how to diagnose
There is an obvious lack of consensus marital and family systems from a general
among family therapists as to the appropriate systems perspective using classroom and
way to view the diagnostic process. Further- clinical training facilities.
more, inappropriate matches between diag-
Intentions of Training Model
nostic tools and units of assessment (i.e.,
system level) creates inconsistency within Following the general rationale presented
camps. For example, a therapist claiming to above, the training model was based initially
deal only with the whole family systems may on four intentions: the experience was de-
on occasion use diagnostic strategies de- signed to facilitate beginning clinicians in:
signed for intrapersonal assessment. Intra- (a) developing awareness of and familiarity
psychic personality tests are specifically de- with the range of available tools and tech-
signed to assess individual properties and niques appropriate for marital and family
using them to assess larger social contents diagnosis, (b) learning to match the clinical
represents confoundment of system levels. problem(s) and system level of interest with
This problem was acknowledged by Bodin a relevant tools and techniques, (c) integrating
decade ago: "Most of our current assessment theoretical perspectives, diagnostic strategy
techniques are designed for use with individ- and treatment plan over various system
uals . . . and are unsuitable for marital and levels, and (d) administering an integrated
family assessment" (Bodin, 1968, p. 233). diagnostic procedure (under supervision) with
This type of problem arises, in part, from a four member clinical family, initially focus-
there not being a systematic guide available ing on the marital dyad followed by assess-
for combining diagnostic strategy with the ments of the total four member family sys-
system level which is of theoretical and tem.
clinical interest. It follows that marital and
Implementation
family therapists need to re-examine their
thinking about diagnosis given the gaps be- The training experience involved a group of
tween theoretical focus and diagnostic prac- twenty students who met for three hours each
tice. We maintain that diagnosis is a crucial week for 15 weeks.2 This total of 45 contact
process of therapy which cannot be neglected
and propose that Ackerman's (1958, p. 9) in- 2Two of the participants were post-doctorates. The ma-
sight is still of age: "A basic problem arises jority of the students were in the doctoral program in coun-

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hours was divided into three basic units each and demonstration would be an appropriate
requiring additional student time outside the formal beginning toward achieving the above
group. Organization of the course was as fol- goals.
lows:
Unit 11:A General Systems Theory
Unit 1: Diagnostic Tools and Techniques Approach to Diagnosis
Beginning with the first session, trainees Most of the trainees had minimal informa-
were introduced to a review and classification tion about or experience with marital or family
of available diagnostic tools and techniques therapy, systems theory, or diagnosis. There-
(Cromwell, Olson, & Fournier, 1976b). Work- fore, Unit II was designed as a general theo-
ing from this codification and description of retical introduction to diagnosing and treating
diagnostic tools, trainees began to develop relationships.
comprehensive abstracts of selected instru- The Erickson and Hogan (1972) reader,
ments, following a structured abstracting Family Therapy: An Introduction to Theory
form.3 Packets of materials were prepared for and Technique was selected as the basic text.
the students that included (a) the abstract This collection of papers was supplemented
form, (b) instructions for abstracting, and by additional readings, lecture and discus-
(c) copies of the original reference work and sion. The primarygoal of this unit was to gain
relevant publications appropriate for com- a general theoretical understanding of the
pleting the abstract. Abstracts were collected systems approach to therapy rather than
weekly for four weeks. Class time was spent develop specific therapeutic techniques.
explaining the abstracting process, reviewing Primary attention was focused on various
the various steps necessary in completing ab- system levels within families to help the stu-
stracts, introducing various tools and tech- dent see the relationships among what we
niques, and demonstrating diagnostic pro- termed "unit of assessment," purpose of
cedures. diagnostic test, and systems level. Ideally,
Utilizing the review and classification of the diagnostician is acutely aware of this in-
available tools and techniques (Cromwell, terface and maximizes the fit among the
Olson, & Fournier, 1976b) as a guide, we were identified clinical problem(s), diagnostic tool,
primarily interested in helping the students and systems level where the problem(s) is
gain an awareness of the range of diag- manifest.4
nostics, learn that different methods provide Building upon the general introduction to
different kinds of information, glean an un- systems theory and familiarity with diagnos-
derstanding of what system level(s) the in- tic tools and units of assessment, a theory of
struments tap (individual, marital dyad, "systemic diagnosis" (Keeney & Cromwell,
partial family, whole family, supra-family), 1977) began to emerge. We define "systemic
the purposes of various techniques, and how diagnosis" to be a way of knowing a given
the techniques have been or can be clinically problematic situation through evaluating
applied. It was our opinion that wrestling with various system levels and their interplay.
abstracts of selected tools and techniques This theoretical approach acknowledges
coupled with classroom discussion, lecture that different diagnostic procedures provide
different types of information. The informa-
tion yielded can be classified by what level of
seling psychology and had completed an introductory system is assessed. Critical to the notion of
course in marital and family counseling. Their clinical
systemic diagnosis is that different system
experience varied widely from "beginning therapists" to
teachers of therapists. Most had limited experience with
family therapy.
4This is not to say that diagnosis need be "problem"
oriented. In the most general sense, diagnosis is primarily
3The abstract form comprised the following categories: helpful if it enables a therapist to develop and evaluate a
(a) title; (b) authors; (c) source; (d) purpose of measure; treatment plan for a couple or family. Diagnosis, then, be-
(e) technique description: physical features, administrative comes an additional way of knowing about the relationship
procedures, sample items; (f) clinical application; (g) fur- in treatment and is a crucial component of the therapeutic
ther comments; and (h) references. process (see Keeney & Cromwell, 1977).

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levels can be assessed and evaluated within a group in at least two family therapy ses-
the context of a multi-system perspective. In sions. The referral organization focuses on
other words, diagnostic information is drawn the family group and enjoys an excellent repu-
from various system levels by tools and tech- tation in the community and among its par-
niques which are appropriately matched to ticipating families. The latter consideration
the particular system level(s) of interest and was a definite asset to clinical application of
the therapist's "need to know." Then the col- the systemic diagnostic procedure.
lected group of bits and pieces of informa- The primary purpose of this unit was to
tion can be interpreted as a whole. That is, the provide a structured training experience in im-
pool of information is evaluated from a gen- plementing a diagnostic strategy rather than
eral systems perspective. This multi-level engaging in family therapy per se. The diag-
systemic approach enables the therapist to nostic information was later interpreted with
obtain a more holistic picture of the proble- the family therapist and follow-up sessions
matic situation. A similar perspective was arranged. The participating families were
earlier suggested by Ackerman (1958, p. 109); informed fully of the purposes of the two part
"clinical diagnosis is perforce only partial strategy and consented to participate. The re-
unless all these elements-individual, role, mainder of this paper describes the structured
family group, and their interrelationships- systemic diagnosis procedures and their out-
are taken into account." come.
Session I: Husband-Wife Dyadic Sub-
Unit 111:Clinical Implementation5
system. There were four components to the
The final phase of the designed experience first diagnostic session. This session was de-
consisted of implementing a two-part sys- signed to include only the husband-wife
temic diagnosis procedure with a four- dyad. The family therapist who had worked
member clinical family. The first procedure previously with the couple introduced team
focused on the marital dyad while the second members and reviewed purposes with the
included two of the couple's children. One of couple. The children were not present.
the children was the "identified patient." The first procedure included administering
There was at least one week between the a structured marital history to each spouse.
dyadic session and the family session. The Marriage History Supplement: Form DD
Given the restrictions of time and lack of was employed. This form was used in the
prior experience, the facilitators elected to NIMH intramural "Courtship and Marriage
utilize a group process model to implement Study" conducted by Ryder and Olson in
the strategy. The 20 students were divided 1968. It contains a thorough demographic
into four five-member teams. Each team profile, a quality of relationship analysis of
worked with one clinical family and each the respondents' parents and in-laws, a
member of the team had specific tasks within marital problems checklist, items on general
the coordinated procedure. marital satisfaction, and open-ended ques-
The four clinical families came from the tions. This form takes approximately 15
same referral source. Sessions were arranged minutes to complete.
by the referral source and were completed in Following the Marital History Supplement,
their clinical setting which was familiar to the both husband and wife completed the Marital
families. The first four families contacted Roles Inventory (Hurvitz, 1965). This self
volunteered to participate. report inventory provides information on mari-
Criteria for participation included: (a) intact tal strain, role performance, and role expecta-
nuclear family with school aged children tions. Husband and wife independently rank
where one of the children was the identified order the importance of each of 11 marital
patient, and (b) the family had participated as roles for themselves and for their spouse.
There are separate, but identical, forms for
both husband and wife which allow for com-
'This section of the training experience was designed in
parisons between spouses as well as analysis
collaboration with colleagues David H. Olson and David G. of individual self reports. This procedure took
Fournier, Family Social Science, University of Minnesota. approximately 30 minutes to complete.

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Trainees explained both of these self report observations," which were not restricted to
forms to the husband and wife, were available the IMC interaction, constituted the fourth
to answer questions, and checked to see if all and final phase of Session I.
information was correctly recorded. -Husband The observations, intended to supplement
and wife were separated during this phase to the more structured procedures outlined
assure independent responses. above, included an assessment of the overall
The third component combined self report relationship quality, interest and involvement
and behavioral observation with administra- in each of the procedures, risk taking, assess-
tion of the Inventory of Marital Conflict (Olson ment of cooperation in decision making and
& Ryder, 1970). This 18-item inventory pro- problem solving, plus a more structural mea-
vides information on a wide range of be- sure of (a) cohesion, (b) adaptability, and
haviors including: relevancy of marital prob- (c) dominance. Each of these latter observa-
lems; an index of who wins conflicts; and tions were recorded after the IMC joint
interaction scores on assertiveness, leader- discussion on a ten-point continuous scale.
ship, communication skills, decision making All diagnostic procedures for Session I
and problem solving. A 1976 revision of the were discussed and demonstrated in the
IMCprocedures was employed. These follow: classroom setting, and all diagnostic ses-
First, the husband and wife are each given sions were supervised. Each group was given
The IMC (a) Relevancy Forms, (b) Case De- a packet of the test materials with instruc-
scriptions and (c) Answer Sheet. tions. The couples were thoroughly debriefed
Second, the couple is then read the Intro- at the end of the session. No couple or indi-
duction to the IMC. vidual refused to participate and all cooper-
Third, the couple is separated so that they ated fully.
can fill out their forms without consulting Session 11:Four Member Family System.
each other. After they have both completed Approximately one week after Session I, the
the forms, they return the Case Descrip- husband-wife dyad participated in a second
tions and Relevancy Form to the person ad- diagnostic session with two of their school-
ministering the procedure but keep their aged children including the "identified
own Answer Sheet. patient." Whereas the first session focused
on the marital subsystem, the second session
Fourth, the couple is taken to a room where
was directed to the four member family
they can discuss and resolve these items.
system. This session was designed to be
This discussion should be tape recorded or
completed in approximately one hour, plus
video-taped for later analysis. The husband
debriefing time.
is then given the IMC Joint Discussion form
As in Session I, different types of diag-
and a pencil. The spouses will also have
nostic tools administered tco different sys-
their own Answer Sheet, but not their Case
tems levels were employed to complete the
Descriptions or Relevancy Forms. Then,
"systemic diagnosis" strategy. Two struc-
the couple is read the Instructions for the
tured assessments were administered and
IMC Discussion Session. The couple is
clinical observations recorded. The family's
given 30 minutes to discuss all items and
therapist was present to introduce the diag-
are reminded of the time after 20 minutes.
nostic team, review procedures, and debrief
Lastly, the husband and wife are given the
after the session.
IMC Post Discussion forms to indepen-
The session began with administration of
dently complete. When they have com-
the self report Family Environment Scale
pleted these forms, it is useful to debrief
(Moos, 1975; Moos & Moos, 1976). The FES
the couple and discuss with them how they
assesses family social environment as per-
felt about the procedure and the way they
ceived by each family member. The scale con-
handled the items.
sists of 90 true-false items that fall into ten
The joint IMCdiscussion was tape recorded subscales, each of which measures the em-
for later analysis. In addition, trainees were phasis on one dimension of family climate
requested to make a series of "clinical obser- (Moos, 1975). The ten dimensions include co-
vations" from the interaction. These "clinical hesion, expressiveness, conflict, indepen-

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dence, achievement orientation, intellectual- table approximately the same size, providing
cultural orientation, active recreational orien- both a frame and a spatial limitation for the
tation, moral religious emphasis, organiza- test material. Clients are asked to place a set
tion, and control. The FES is designed to of wooden sculptures on the board (the sculp-
assess " . . . the interpersonal relationships tures represent their family members) in a
among family members, on the directions of manner representative of their family relation-
personal growth emphasized within the fam- ships. There are 13 sculptures or figurines in
ily, and on the basic organizational structure Kvebaek's original test set: 4 grandparents, 2
of the family" (Moos & Moos, 1976, p. 358). parents, 4 children, 2 "third persons," and 1
While the FES has primarily been utilized (or 2) family pets. This allows sculptures of
as a clinical research instrument, it appears to the extended family and relevant social net-
have potential diagnostic utility. It was in this work.
context that the decision was made to include In our clinical application, only figurines
it within the systemic diagnosis strategy. representing the nuclear family of the volun-
Each family member independently com- teers were utilized. While only four family
pleted the FES. This procedure provided four members participated in the diagnostic
self reports on the same family social environ- session, figurines representing the entire
ment. These reports can be interpreted indi- nuclear family were utilized (ranging from five
vidually or in combination. Family profiles to seven figurines). The overall procedure em-
and discrepancy scores can also be created. ployed consisted of two separate tasks each
School aged children had no difficulty read- with two subdivisions. Individualfamily mem-
ing or comprehending the items or in com- bers were asked to independently sculpt both
pleting the true-false scoring sheet. Trainees their "real" family relationship and their
were available to answer questions or inter- "ideal." The first is a representation of their
pret items if necessary. The FES is completed individual perception of their family relation-
in approximately 30 minutes. ship in the "here and now" while the second
The second major component of the family provides a picture of how they would like to
diagnostic session involved completion of the change the present situation. The second task
Kvebaek Family Sculpture Technique (KFST) requires the family to work together to provide
(Kvebaek, Note 2; Cromwell & Kvebaek, Note a "family consensus" real and ideal sculp-
3). This technique was originally developed as ture. The verbal family interaction was tape
a diagnostio aid in family therapy in Norway recorded.
by family therapist -David Kvebaek out of a Individual sculptures were completed inde-
"need to express himself visually (while doing pendently in different rooms and both the
family therapy), and also partly from the diffi- "real" and "ideal" sculptures were recorded
culty experienced in trying to remember the on a score sheet replicating the 10 x 10 grid.
many different constellations and interac- Final placements, order of placement, and
tions in family groups" (Kvebaek, Note 2, p. movement of -each figurine were recorded.
1). Each family member was encouraged to dis-
The KFST was first introduced to clinicians cuss their placements during both tasks.
in the United States in 1974 by Kvebaek The "family consensus" sculpture followed
during a tour to several family studies pro- completion of each member's individual
grams and clinics. The unpublished English sculptures. This situation provides an oppor-
translation of his diagnostic technique tunity to view family interaction structured by
received limited circulation but it has been a task now famIliarto each family member. As
referenced in the review of diagnostic tools in the individual procedure, family members
and techniques by Cromwell, Olson and Four- are encouraged to discuss their placements
nier (1976a, 1976b) and applied in clinical and resolve differences in reaching consen-
settings by these authors. sus on both their group perception of the
In brief review, the KFSTconsists of a 1 x 1 "real" and "ideal" family relationship. Final
meter board visually divided into a 10 x 10 placements, order of placement, and move-
square grid. It is designed to be used on a ment of figurines for both tasks were recorded

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on the score sheet and verbal interaction tape In the class syllabus, the final sentence
recorded for analysis. read: "Please trust the process. . . the
Individual and family sculptures can be course may be a bit confusing and difficult at
completed in 30 minutes when using a team first." Most students did trust the process (al-
approach with three sculpture boards in oper- though six dropped the class the first week,
ation at the same time. Both consistencies leaving the enrollment at 20), and initially
and inconsistencies within and across indi- expressed some confusion. The abstracting
vidual and family sculptures constitute rich process called for evaluative skills of diag-
sources of diagnostic information difficult to nostic tools and techniques relatively un-
obtain by other means. When the members familiar to the students. The quality of the ab-
have completed all tasks, the diagnostician/ stracts varied greatly. Editing, revision, feed-
therapist has at hand both qualitative and back, and individual tutorials helped clarify
quantitative information on the family sys- this assignment and by the end of the unit
stem, sub-systems, and individual com- most students had achieved the purposes
ponents. The unit of assessment clearly is the established.
family. The struggles experienced in the first unit
A third component to the second diagnos- did help set the stage for the theoretical com-
tic session involved a repeat of the "clinical ponent of the class. More specifically, the
observations" procedure followed in session focus on purposes of the diagnostic tools, the
one. The observations were expanded to in- appropriate unit of assessment (or system
clude the four member family system and level attended), and clinical application of the
structured observations were recorded on ten technique helped the student become sensi-
point continuous scales for adaptability, co- tive to systems dynamics within family
hesion and dominance. This constituted the groups. Classroom discussion and demon-
final procedure in the clinical application of stration interfacing systems concepts with
the systemic diagnostic strategy which had their assessment facilitated the integration of
been designed in the classroom. "systemic diagnosis."
The training experience terminated with
Outcome
completion of student write-ups. Time did not
This paper has described an initial attempt permit formal follow-up with the students nor
to focus exclusively on the theory, methodol- complete interpretation of the information
ogy and clinical implementation of diag- collected. This has been accomplished to
nosing marital and family systems. The some extent through written contact with
greatest single weakness of the training each student. The major recommendation
model was the lack of time to facilitate fully concerning this form of training model is that
the integration of substantive information and it be expanded to a two semester experience
clinical application. More specifically, our which would provide the time necessary to
overall expectations for the experience may complete the systemic diagnosis discussion,
have been too utopian given the limitations of interpretation, and appropriate follow-up with
students' therapeutic skills and knowledge of the students. Students would also participate
the subject matter. One semester is not in the debriefing with the family therapist and
enough time to integrate the material pre- observe sessions with the participating fam-
sented in the three unit sequence. ilies.
While we have confidence in the format of The family therapists who assisted and
the training model, it is our opinion that the provided the referrals, however, were
sequence should be broadened to encompass thoroughly briefed with case presentations
at least two semesters. Each student did for their use in follow-up sessions with the
complete, on time, the required systemic families. The therapists who were involved
diagnostic write-up on their family including reported the training experience to be a sig-
clinical observations. These were combined nificant part of ongoing efforts with their fam-
in the form of a group case presentation for ilies. Furthermore, some commented that
each family. their involvement helped to advance their own

January 1979 THE FAMILYCOORDINATOR 107

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growing edge. Cromwell, R. E., Olson, D. H., & Fournier, D. G. Diagnosis
In concluding it may be noted that the train- and evaluation in marriage and family counseling. In D.
H. Olson (Ed.), Treating relationships. Lake Mills, Iowa:
ing model was most basically rooted to the
Graphic, 1976. (b)
perspective of general systems theory. Erickson, G. D., & Hogan, T. P. (Eds.). Family therapy: An
Diverse system levels of the clinical situa- introduction to theory and technique. Monterey: Brooks/
tions being examined were regarded as poten- Cole, 1972.
tially relevant. Concomitant to the therapeutic Fisher, L. Dimensions of family assessment: A critical re-
view. Journal of Marriage and Family Counseling, 1976,
emphasis on multi-systems, the training 4, 367-382.
model bridged multi-levels of experience, at- Haley, J. Critical overview of present status of family inter-
tempting to integrate methodology, theory, action research. In J. L. Framo (Ed.), Family interaction:
and clinical application. A dialogue between family researchers and family thera-
pists. New York: Springer, 1972.
Hobbs, N. Mental health's third revolution. American Jour-
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